1 


PERKINS  LIBRARY 

Duke   University 


Kare  Dooks 


__; 


C 


/j<*/<&U 


<{«<''^f       ~    &*^-" 


) 


\ 


THE 


PRINCIPLES 


OF 


S  U  11  G  E  R  Y 


Bij  JOHN  BELJL  Surgeon. 


ABRIDGED    BY 

J.  AUGUSTINE  SMITH, 

OF    THE    ROYAL  COLLEGF  OF  SURGFONS,    LONDON',    AM. 
PROFESSOR  OF   ANATOMY,  SURG  I  RY  AND  PHYSIOLOGY 
IN    THF.   COLLEGE   OF    PHYSICIANS   AND 
SURGEONS    IN    THt    UNIVER- 
SITY OF  THE  STATE  OF 
NEW-YORK, 


SECOND  EDITION   WITH  NOTi.S  AND  ADDITIONS. 


NEW-YORK  : 

PRINTED  AND  SOLD   BY  COLLINS  &  CO.    NO.   189,' 
PEARL-STRELT. 

1812. 


Diflrict  of  New-York,  f. 

JJE  if  REMEMBERED  that  on  the  twelfth  day  of  December,  in 
the  thirty  fixth  year  of  the  Independence  of  the  United  States  of 
(L.  S.)  America,  Collins  &  Co.  of  the  (aid  DiftricT:,  have  dtpoCted  m  this 
office  the  title  of  a  book,  the  right  whereof  they  claim  as  proprietors, 
in  the  words  following,  to  wit  • 

w  Tbe  Principles  of  Surgery— By  "John  Bell,  Surgeon — Abridged  b\  J.  Augustine 
Smith, of  the  Roxal  College  of  Surgeons,  London,  and pt of effor  of  Anatomy,  Surgery  and 
JPbxsio'ogx,  in  the  College  of  fbyftcians  and  Surgeons  in  tbe  Uni-verfity  of  tbe  State 
of  New-York— Second  Edition,  "with  Notes  and   Additions.'* 

IN  CONFORMITY  to  the  A&  of  the  Congrefs  of  the  United  States,  entitled, 
"  An  Aift  for  the  Encouragement  of  Learning,  by  ftcuring  the  Copies  of  Maps, 
Charts  and  Books,  to  the  Authors  and  Proprietors  of  fuch  Copies,  during  the 
time  therein  mentioned  ;"  and  alio  to  an  A<5t,  entitled,  "An  Act  fupplementary 
to  a:.  A&.,  entitled,  An  A&  for  the  Encouragement  of  Learning,  by  fecuring  the 
Copies  of  Maps,  Charts,  and  Books,  to  the  Authors  and  Proprietors  of  fuch  t  opies, 
during  the  times  therein  mentioned,  and  extending  the  benefit*  thereof  to  the  Arts 
of  Designing,  Engraving,  and  Etching  Hiftorkal  and  other  Prints." 

CHARLES  CLINTON, 
Clerk  of  tbe  Diflrict  of  New -York. 


. 


EDITOR'S 


PREFACE 


1  HE  great  celebrity  and  acknowledged  merit  of  Mr. 
John  Bell's  Principles  of  Surgery,  render  it 
entirely  unnecessary  for  me  to  say  any  thing  in  their 
praise.  '  In  the  Edition  of  them  now  presented  to  the 
public,  care  has  been  taken  to  select  those  parts  which 
were  deemed  most  useful  and  important.  Mr.  Bell's 
descriptions  of  diseases  and  operations,  which  are  un- 
rivalled by  any  modern  surgical  writer  in  animation 
and  effect,  are  retained  .almost  verbatim,  and  when- 
they  were  thought  not  sufficiently  full  and  minute, 
the  additions  which  were  deemed  requisite  will  be 
found  in  a  note  distinguished  by  the  letter  S,  at  the 
foot  of  the  page.  Where  I  have  differed  in  opinion 
from  Mr.  Bell  on  a  point  of  practice,  his  opinion  is 
stated  in  the  text,  and  mine  in  a  note,  so  that  the  reader 
can  adopt  that  which  lie  may  think  preferable. 

a' 


Since  the  chapter  on  Adhesion  was  printed,  I  have 
read  Mr.  Young's  animadversions  upon  the  practice 
there  recommended  by  Mr.  Bell,  but  think  no  further 


IV  PRETACE. 

cautions  necessary  with  regard  to  the  use  of  sutures  in 
promoting  the  re- union  cf  divided  surfaces. 

Since  the  publication  of  the  first  volume  of  the  Prin- 
ciples of  Surgery,  Dr.  Jones  has  written  a  most  valua- 
ble work  nn  Haemorrhage  ;  in  the  Appendix  the  reader 
will  find  an  account  of  his  discoveries  and  observations 
on  that  subject ;  and  in  the  third  number  of  the  New- 
York  Medical  and  Philosophical  Journal  and  Review, 
a  most  ingenious  defence  of  Mr.  Bell,  by  Dr.  Davidge 
of  Baltimore. 

Since  that  period  also,  the  celebrated  Scarpa  has  writ- 
ten a  work  upon  Aneurism,  in  which  he  differs  from 
Mr.  Bell,  and  indeed  all  his  immediate  predecessors, 
as  to  the  manner  in  which  these  tumours  are  formed. 
Appendix  D  will  enable  the  reader  to  judge  of  the  cor- 
rectness of  Scarpa's  doctrine. 

I  have  deemed  it  unnecessary  to  transcribe  Mr.  Bell's 
observations  intending  to  prove  that  the  inosculating 
vessels  are  sufficient  to  support  a  limb  when  the  main 
artery  is  tied,  as  no  Surgeon  is  now  deterred  by  the 
fear  of  mortification  from  tying  any  accessible  artery 
in  the  human  body.  Three  instances  tof  this  have 
however  occured,  two  are  related  in  Wishart's  appen- 
dix to  Scarpa,  and  one  in  the  Medical  and  Physical 
Journal  for  April  1809. 

With  regard  to  the  best  method  of  treating  fractures 
of  the  lower  extremities,  I  never  doubted  that  a  state 
of  flexion  and  consequent  relaxation  of  the  muscles 

during  the  tendency  to  inflammation,  was  the  Lest  po- 


PREFACE.  V 

sition  in  which  they  could  be  placed,  until  I  understood 
that  Dr.  Physick  entertained  a  different  opinion  and 
taught  a  contrary  practice.  So  great  is  the  deference 
which  I  pay  to  the  judgment  of  Dr.  Physick,  that  I 
am  now  not  without  my  doubts  on  the  subject ;  as  liow- 
ever  I  have  uniformly  practised  the  plan  recommended 
by  Mr.  Bell,  and  have  never  seen  any  ill  consequences 
from  it,  I  have  deemed  it  unnecessary  to  state  any  ob- 
jections to  his  mode  of  treating  these  accidents.  But 
where  the  thigh-bone  is  fractured  at  its  neck  or  near  its 
trochanters,  then  undoubtedly  the  straight  position  is 
the  best,  and  Beyer's  apparatus*  I  should  think  superi- 
or to  Dcsault's  ;  either,  I  am  afraid,  would  fail  in  a 
strong  muscular  subject,  the  latter  certainly  has.f 

Mr.  Bell  gives  the  diagnostic  symptoms  and  appear- 
ances which  distinguish  fractures  of  the  neck  ol  the 
thigh-bone  from  luxations  of  the  hip-joint,  but  says 
nothing  of  the  method  of  reduction  to  be  employed  in 
this  latter  case.  In  the  appendix  G,  the  reader  will 
find  directions  for  that  purpose. 

*  For  a  description  and  plate  of  this  apparatus,  the  reader  may- 
consult  Boyer's  Lectures  on  the  Bones,  translated  by  Farrel,  Ilarts- 
horne's  edition,  p.  124. 

f  I  cannot  speak  ol' this  machine  from  experience,  not  having  met 
with  a  case  since  I  procured  one  of  them.  There  is  a  case  related 
in  the  third  Supplement  to  the  Medical  and  Physical  Journal,  of  com- 
plicated fracture  of  the  trochanters,  where  this  machine  was  used, 
in  which  the  fractured  portions  were  found  in  apposition  after  death. 
This  proves  nothing.  There  can  be  no  difficulty  in  overcoming 
the  action  of  the  muscles,  in  a  debilitated  patient  and  one  dying 
froai  mortification  and  diarrhoea,  so  that  the  fractured  bones  should 


R9SS71 


VI  FREFACt. 

I  have  retained  all  that  Mr.  Bell  says  upon  the  symp- 
toms of  the  stone,  on  which  he  is  perhaps  rather  con- 
cise, but  I  thought  there  was  no  occasion  for  making 
any  further  observations  upon  them  as  the  distinct  per- 
ception of  the  stone,  by  the  sound,  can  alone  warrant  the 
operation  of  Lithotomy.  I  have  omitted  the  history 
of  the  operation  and  the  various  Ways  of  performing  it, 
convinced  that  the  Gorget  is  the  best  instrument  and 
the  only  one  which  most  Surgeons  will  use.  As  to  its 
occasionlly  passing  through  the  fundus  of  the  bladder, 
or  between  that  viscus  and  the  rectum,  the  former  oc- 
currence is  certainly  very  rare,  and  both  are  to  be  attri- 
buted to  the  operator  rather  than  to  the  instrument. 
And  what  mischief  would  not  that  Surgeon  do  who 
should  attempt  to  cut  for  the  stone  with  the  knife  alone, 
when  he  was  incapable  of  passing  the  Gorget  into  the 
bladder? 

It  is  unnecessary  for  me  to  point  out  all  the  omissions 
which  I  have  made.  They  will  be  found  to  consist 
principally  of  histories,  anecdotes,  and  operations,  and 
machines  now  no  longer  in  use.  Some  apology  may 
be  thought  due  to  Mr.  Bell  for  thus  abridging  his  work, 
but  when  it  is  remembered  that  his  object  in  writing 
must  have  been  the  benefit  of  his  profession,  and  through 
it  the  good  of  mankind,  he  can  not  be  offended  at  hav- 
ing his  fame  and  usefulness  thus  diffused  through  this 
extensive  country. 


CONTENTS 


DISCOURSE  I. 


O, 


Page 


'F  Adhesion 1 

Oi  Sutures              ......  3 

Rules  for  the  re  union  of  wounds  of  the  Skin  .  .  5 
Rules  for  the  re-union  of  oeep  muscular  wounds  .  .  7 
Rules  for  the  re-union  of  complicated  wounds,  where  there 

is  a  wounded  artery  or  fractured  bone  .  .  8 
Of  cutting  out  the  stitches  .  .  .  .10 
Description  of  those  wounds  in  which  adhesion  is  not  easily 

obtained,  and  of  the  accidents  by  which  it  is  prevented  ib. 

DISCOURSE  II. 

Of  ill  conditioned  and  complicated  wounds             .             .  12 

Of  ulcers              ......  20 

Of  Hospitalpsore  or  gangrene  .  .  .  .25 

DISCOURSE  III. 

Of  the  various  uses  of  bandages             .             .  30 

Of  the  four-tailed  bandage              .              ...  37 

Of  applying  a  roller  to  the  head  and  jaws               .              .  39 

Of  bandage  for  the  body                .             .             .             .  41 

DISCOURSE  IV. 

On  lvjemorrhagy               .....  43 

Of  the  natural  causes  by  which  an  haemorrhagy  is  stopped  44 


Vlii  CONTENTS. 


Page 
Of  the  artificial  means  of  suppressing  haemorrhage  45 

Oltne  condition  )f  an  artery  when  tied  with  a  ligature  48 

Of  the  causes  of  secondary  hamorrhagy,  and  first  of  the  burst- 
ing of  the  artery  from  the  diseased  state  of  its  coats  49 
Of  the  bursting  of  the  artery  from  ulceration  of  its  coats                5 1 


DISCOURSE  V. 

Description  of  aneurism  55 

Of  various  anomalous  cases  of  aneurism  .             .             65 

Aneurism  from  fracture  of  the  bones              .  .              .67 

Peculiarities  of  popliteal  aneurism              .  .              .              71 

Of  the  progress  of  aneurism  and  their  cure  .             .           73 

•Hunter's  operation              .....  76 


DISCOURSE  VI. 

Of  the  formation  of  an  aneurism  over  a  wounded  artery  .        78 

Of  the  operation  for  such  an  aneurism             .             .  .79 

Rules  of  practice               .....  84 


DISCOURSE  VII. 

Of  wounds  of  arteries             .             .             .            .  .85 

Of  wounds  of  superficial  arteries                ...  86 

Of  an  artery  wounded  with  a  lancet             ...  92 

Of  aneurismul  varix              .....  93 

Of  oblique  wounds  of  arteries             .             ..            .  .95 

Of  wounds  of  the  thoracic  artery             .             .             .  101 


DISCOURSE  VIII. 

Of  aneurism  from  anastomosis            .            .  .        .       102 

DISCOURSE  IX. 

On  fractures  of  the  limbs            .             .             .  .            m 

Ol    lie  formation  nf  callus              •              •              .  .              ib. 

Definition  of  fractures            .             .             .  ..116 


CONTENTS, 


DISCOURSE  X. 

Page 
Rules  for  the  management  of  simple,  compound  and  gun-shot 

fractures  .  .  .  .  .  .121 

Of  simple  fracture  .....  123 

Of  the  fracture  of  the  humerus         .  .  .  .         ib. 

of  the  fore-arm  .         .         .  .  .  124 

of  the  clavicle       ....  125 

of  the  sternum  .....  126 

of  the  ribs  ......  ib. 

of  the  spine  .  .  .  -127 

of  the  lower  extremity         .  .         .  128 

of  the  thigh  .  .  .  .129 

of  the  patella  .  .  .  .132 

of  the  olecranon  .  .  .  .         .  133 

Rupture  of  the  tendo  achillis         .  ....  134 

Concluding  observations  on  simple  fractures         .         .         .136 
Rules  for  compound  fracture  .         •  .  .  138 

Of  gun-shot  fracture.        .         .  .....  146 

Of  complicated  fracture  .  .  .  .  147 

DISCOURSE  XI. 

On  the  accidents  and  diseases  of  the  hip-joint         .  .         .     150 
Diagnosis  of  the  various  affections  of  this  joint         .         .  ib. 

Of  luxation  of  the  femur  downwards     .         .         .  .         .158 

Of  luxation  of  the  femur  upwards  .  .         .  .  .162 

Pathology  of  the  diseased  acetabulum  .  .  .163 

Of  the  scrofulous  disease  of  boys,  affecting  this  joint  .  .164 

DISCOURSE  XII. 

Of  lithotomy      .             .  .             .             .  .              171 

Of  the  external  incision  .              .             .  .              179 

Of  cutting  the  urethra  .          .         .         .          .  .          .181 

Of  introducing  the  gorget  .         .         .         .  .          .          1 82 

Of  extracting  the  stone  .         .         .         .  .         .          183 

Of  the  causes  of  the  slipping  of  the  gorget  .         .          134 

Operation  of  lithotomy 188 

DISCOURSE  XIII. 

Of  obstruction  of  urine         .         .         .  .         .         .192 

Of  introducing  the  catheter  .  .  .  .         ib 


.(•• 


CONTENTS. 


DISCOURSE  Xl\  . 


Of  the  various  causes  of  obstruction  of  urine^ 

Of  stricture 

Of  fistulx  in  the  perinxum  and  urethra 

Of  the  causes  of  fistulsc 

Of  the  cure  of  fistula 


Page 

199 

ib. 

209 
210 
220 


DISCOURSE  XV. 

Of  total  obstruction  of  urine  and  puncturing  the  bladder  224 

Of  distention  and  rupture  of  the  bladder             .             •  226 

Of  the  several  methods  of  puncturing  the  bladder           •  .     232 
Of  puncturing  above  the  pubes           .....          233 

Of  cutting  into  the  bladder  from  the  perinaeum           .  .         234 

Of  passing  a  trocar  into  the  bladder  from  the  perinsum  2o7 

Of  tapping  the  bladder  from  the  rectum     .         .         .  .239 

Of  forcing  the  catheter  into  the  bladder         .         .  ■       .  .     240 

DISCOURSE  XVI. 


On  the  anatomy  of  the  cranium,  and  the  rules  of  practice  to 

be  deduced  from  it  . 

Of  trepanning  the  frontal  sinus 

DISCOURSE  XVII. 


243 
251 


Pathology  of  the  integuments,  scull  and  dura  mater 

On  the  vitality  and  connections  of  the  scull 

Of  injuries  of  the  scalp 

Of  separation  cf  the  ciura  mater  .         . 

Of  contusio  cranii  

Of  suppuration  of  the  brain  .... 


256 
ib. 
259 
274 
280 
291 


DISCOURSE  XVIII. 


Of  fractures  of  the  scull 

Of  fractures  of  the  scull  with  depression 

Of  casec  requiring  the  trephine  and  lever 


301 
31 J 
327 


DISCOURSE  XIX. 


On  the  states  of  concussion  and  depression 
Of  concussion 
Of  compression 


34S 
345 
34S 


CONTENTS.  Xi 

Page 
Of  the  operation  of  the  trepan  ....     360 

Aphorisms  or  rules  of  practice  .  .  .  .      366 

DISCOURSE  XX. 

On  Tumours  .....  373 

Of  the  parts  most  subject  to  tumours  .  .  .      376 

DISCOURSE  XXL 
On  tumours  of  the  bones  ....  383 

DISCOURSE  XXII. 
On  tumours  of  the  nostrils,  gums  and  throat  .  .      405 

DISCOURSE  XXIII. 

Of  the  various  operations  practicable  in  the  several  stages 

of  polypus              .             .             .             .             .  427 

Of  the  first  stage  or  small  and  incipient  polypi             .  .       ib. 

Of  the  second  stage  of  polypus,  or  of  large  and  guttural 

polypi             ......  439 

Of  the  third  and  last  stage  of  polypus            .                      .  465 

DISCOURSE  XXIV. 

Of  tumours  of  the  gums,  lips,  cheeks  and  throat  472 

DISCOURSE  XXV. 

On  salivary  tumours  .  .  .  .  .521 

APPENDIX. 
A 

Of  the  process  employed  by  nature  in  the  suppression  of 

haemorrhage  .  .  .  .  .551 

B 

« )n  the  effect  of  ligatures  upon  arteries  .  .        ►      SS9 


xil  GONTENTS. 

C  » 

Page 
Further  observations  upon  secondary  haemorrhage  .  553 

D 

Scarpa's  doctrine  with  regard  to  the  formation  of  aneurisms         555 

E 
Further  observations  upon  the  same  subject  .  •  .         559 

F 
Directions  for  performing  the  operation  for  popliteal  aneurism     560 

G 
Directions  for  reducing  luxations  of  the  hip-joint        .        .         561 


PRINCIPLES 


OF 


SURGERY 


DISCOURSE  I. 


SECTION    T. 


Of  Adhesion. 

X  HE  modern  doctrine  and  practice  of  procuring  adhesion,  for 
which  we  are  more  particularly  indebted  to  Mr.  Hunte rand  the 
London  school,  has  done  more  for  Surgery  in  a  few  years,  and 
most  especially  for  the  Surgerv  of  Wounds,  than  any  other  ge- 
neral observation,  not  excepting  even  the  greatest  of  all  disco- 
veries, the  circulation  of  thi  blood.  It  is  now  well  proved, 
that  skin  will  adhere  to  skin,  fiVsh  to  flesh,  bone  to  bone,  and  all 
these  parts  to  each  other.  One  part  only  of  the  human  bodv, 
cartilage,  will  not  adhere.  I  have  seen  manv  proofs  that  carti- 
lage does  not  inflame,  nor  ulcerate,  nor  give  out  granulations, 
nor  generate  new  flesh  ;  or,  at  least  it  does  so  very  slowlv  :  a 
wound  heals  over  a  cartilage  without  adhering  to  it.  We  am- 
putate a  toe  at  the  joint,  and  the  flaps  unite  in  two  days  ;  but 
still  they  have  united  with  each  other  only,  and  not  with  the 
cartilage  at  the  joint :  and  in  a  luxated  limb,  we  find  that  the 
bone  continues  displaced,  the  cartilage  never  inflames,  nor  ever 

A 


£  Of  Adhesion. 

unites  with  the  lacerated  parts,  for  the  process  of  adhesion  is 
really  this  :  either  the  arteries  of  opposite  surfaces  inosculate 
mouth  to  mouth,  or  each  cut  surface  throws  out  a  mucus,  into 
which  the  lesser  arteries  of  the  divided  part  elongate  them- 
selves ;  and  it  is  thus,  or  perhaps  by  the  generation  of  a  new  in- 
termediate substance,  that  the  continuity  of  the  part  is  so  quick- 
ly restored.  If  any  one  point  fail  to  adhere,  there  the  wound 
must  run  into  suppuration,  because  at  that  point  there  is  a  sepa- 
ration of  parts,  which,  being  equivalent  to  a  loss  of  substance, 
requires  the  generation  of  new  flesh. 

When  the  opposite  surfaces  consent  and  harmonize  with  each 
other  in  their  mode  and  period  of  action,  then  they  immediate- 
ly adhere  ;  but  if  one  of  the  opposite  parts  enters  instantly  into 
a  lively  action,  while  that  of  the  other  is  comparatively  languid, 
such  parts  do  not  harmonize,  and  consequently  will  not  unite  ; 
but  they  may  live  and  thrive  independently  of  each  other ;  and, 
perhaps  in  this  way  it  may  happen,  that  opposite  surfaces  of 
skin  or  muscle  may  seem  to  be  adhering  firmly  to  the  parts  be- 
neath them,  while  they  adhere  to  each  other  only,  and  merely 
cover  the  cartilage  or  bone,  without  having  any  direct  connex- 
ion with  them.  The  bone,  as  we  see  in  an  old  amputated  limb, 
lives  and  thrives,  is  not  limited  in  its  new  formation  by  the  ad- 
hesion of  surrounding  parts,  but  grows  out  into  a  broad  knob  of 
callus  or  new  bone*  Cartilage  also,  as  in  an  amputated  or  luxa- 
ted joint,  retains  its  pure  and  lubricated  form. 

There  are,  no  doubt,  accidents  both  of  the  constitution  and  of 
the  wound  which  will  prevent  adhesion;  for  if  the  patient  be  of 
a  bad  habit  of  body,  if  he  be  lying  in  a  foul  hospital,  and  breath- 
ing infected  air,  if  he  be  ill  of  a  fever  or  a  flux,  or  any  general 
disease,  then  the  powers  of  his  system  being  debilitated,  his 
wound  will  not  adhere  ;  or  if  the  wound  be  foul,  made  with  a 
poisoned  weapon,  or  left  with  foreign  bodies  sticking  in  it ;  or  if 
blood  be  poured  out  into  the  cavity  of  the  wound,  for  blood  in 
this  case  is  but  a  foreign  body*,  or  if  there  be  a  wounded  lym- 
phatic, salivary  duct,  or  intestine,  or  a  bleeding  artery  or  vein — 
any  of  these  causes  will  prevent  an  immediate  adhesion  of  the 
wound  :  or  if  it  be  a  bruised  or  gun-shot  wound,  and  there  is  a 
destruction  of  parts,  the  loss  must  be  supplied,  and  those  parts 
which  remain  must  enter  into  a  new  action  for  that  purpose,  and 
consequently  cannot  adhere. 

This  adhesion,  then,  is  a  property  of  the  parts  of  the  living 

*  If  the  extravafated  blood  be  in  reality  a  foreign  body,  how  can  it  ever  become 
the  medium  of  re-union  between  the  divided  furfaces,  which  it  certainly  does  ir< 
fome  inftances  ?  For  a  much  more  ample  and  latisfaelory  account  of  adhefion  be- 
tween divided  furfaces,  vide  Hunter  on  the  Blood,  p.  189,  and  feq.    S. 


Of  Sutures.  z 

body,  which  is  perfect  only  when  their  structure  is  entire,  which 
operates  only  when  the  opposite  surlaces  touch  each  other  by 
the  fullest  contact,  and  sympathize  with  each  other  in  their  pe- 
riod and  degree  of  action.  Adhesion  then  is  interrupted  if  any 
foreign  body  is  interposed  :  it  is  less  perfect  in  every  unhealthy 
condition  of  the  system,  but  it  is  a  property  of  which  we  are 
now  so  well  assured,  that  we  look  for  its  good  effects  in  the 
greatest  as  well  as  in  the  smallest  wound,  and  the  union  of  an 
hare-lip,  after  it  has  been  cut  and  pinned,  represents  the  perfec- 
tion of  that  cure,  which  we  attempt  in  every  greater  operation, 
and  more  confidently  in  every  smaller  wound,  succeeding  some- 
times as  perfectly  after  an  amputation  of  the  thigh  as  after  the 
most  trivial  cut  in  the  cheek. 

This  property  of  re-union  between  divided  parts  is  proved  by 
every  day's  experience  to  be  so  perfect,  that  when  we  do  fail, 
which  no  doubt  is  sometimes  owing  to  a  bad  habit  of  body,  we 
have  some  reason  to  suspect  some  negligence  on  our  own  part, 
some  extravasated  blood,  some  open  artery,  some  portion  of 
detached  bone  left  in  the  wound,  or  some  awkward  piece  of 
dressing  laid  in  betwixt  its  edges  ;  we  have  reason,  in  short,  to 
blame  the  want  of  that  absolute  contact  which  is  so  essential  to 
perfect  adhesion,  as  every  part  of  a  wound  which  does  not 
touch  some  opposite  surface,  must  suppurate  before  it  can  heal  ; 
and  this  is  my  chief  motive  for  putting  down  carefully,  in  short 
distinct  rules,  the  several  ways  in  which  the  sides  of  a  wound 
mav  be  brought  together,  so  as  to  adhere  perfectly. 

There  is  no  incised  wound  in  which  we  may  not  try,  with  safety, 
to  procure  this  adhesion* :  nothing  surely  can  be  more  kindly 
when  applied  to  a  wounded  surface,  than  the  opposite  surface  of 
the  same  wound.  It  has  been  but  just  separated,  it  may  immedi- 
ately adhere  to  it,  and  though  it  do  not,  no  harm  is  done  :  still 
the  wound  will  suppurate  as  kindly,  as  freely,  as  if  it  had  been 
roughly  dressed  with  dry  lint,  or  some  vulnerary  balsam  or 
acrid  ointment. 


SECTION    II. 

Of  Sutures. 

For  the  purpose  of  bringing  divided  surfaces  into  contact, 
surgeons  employ  what  are  termed  sutures  :  these  are  either  dry 
or  bloody  :  the  former  are  made  with  sticking  plaster,  the  lat- 


•  In  injuries  of  the  head,  this  rule  fhould  not  be  too  ftridly  obferved.     Rear} 
what  is  faid  upon  that  fubject  in  the  Chapter  on  Injuria  r,f  the  Head.    S. 


4  Of  Sutures. 

ter  with  needles  and  thread.  The  dry  suture  is  made  some- 
times with  gum,  as  in  our  common  court-plaster,  which  is 
m<  rely  gum  arabic,  with  a  little  laudanum  added  to  it,  spread 
upon  black  silk.  The  older  surgeons  often  used  glue,  some- 
times whites  of  eggs,  for  we  find  that  their  agglutinative  plasters 
took  two  hours  in  drying,  which  shews  that  they  were  made 
merelv  of  glue.  But  these  are  dissolved  by  the  moisture  which 
flows  from  a  great  wound,  therefore  in  amputation  and  all  great 
Wounds,  we  are  obliged  to  bttake  ourselves  to  adhesive  plas- 
ters, made  of  wax,  resin,  and  oil*;  though  straps  of  that  kind 
are  far  from  being  pleasant  to  use,  for  they  must  be  applied  ex- 
ceedingly warm,  and  the  slightest  degree  of  moisture  on  the  ad- 
jacent skin  prevents  their  adhering. 


Fig.  3. 


r. 


' 


T&i. 


The  bloody  suture  is  of  various  forms,  the  first  the  inter- 
rupted suture,  (Fig.  1st.)  when  in  place  of  making  the  stitches 
close,  and  continuous,  as  in  a  seam  of  cloth,  the  surgeon  just  pass- 

This  plate  reprefents  the  various  futures  ufed  by  the  modern  .furgeon,  and  as 
each  future  is  defcribed,  the  particular  figure  in  this  plate  explaining  fuch  future 
will  be  marked. 

•  By  far  the  belt  adhefive  plafter,  for  all  purpofes,  is  the  Emp.  Lythareyri  cum 
relina  of  the  Pharm.  Lond.    S.  r      /       5/ 


Of  Wounds  of  the  Skin.  5 

ed  the  needle  once  through  both  lips  of  the  wound,  taking  care  that 
the  needle  passed  us  near  the  bottom  ot  the  incision  as  pos- 
sible, tied  the  ligature  and  cut  the  ends  away,  and  r<  peateci  the 
stitch  from  point  to  point,  all  along  the  wound:  the  several 
stitches  are  usually  about  an  inch  distant  trom  each  other, tare  be- 
ing taken  to  put  one  at  every  angle  al  the  wound.  From  this  it 
was  named  the  interrupted  suture,  and  is  almost  the  only  one 
of  this  class  now  employed.  Some  surgeons  yet  retain  the 
hare-lip  suture,  as  it  is  called,  from  being  principally  used  alter 
operating  lor  that  deformity.  It  is  made  by  thrusting  pins  or 
needles  through  both  lips  ot  a  wound,  and  twisting  a  fine  thread 
around   their  projecting  ends ;  whence   it    is   olten  named  the 

TWISTED     SUTURE*.  1 


SECTION    III. 

Rules  for  the  Re-union  of  Wounds  of  the  Skin. 

In  all  cases  where  the  divided  edges  of  the  skin  can  be 
brought  into  contact,  and  retained  so  by  sticking-plaster  and 
bandage,  they  are  to  be  preferred  to  ligatures,  as  the  latter,  act- 
ing as  extraneous  bodies  in  the  wound,  alwavs  excite  some  de- 
gree of  inflammation;  but  they  answer  the  intention  with 
which  they  are  used  much  more  certainly  than  the  former ; 
particularly  in  many  parts  of  the  face,  to  which  bandages  can- 
not be  applied  with  any  considerable  effect,  and  the  adhesive 
plasters  alone  are  not  sufficient  where  the  parts  have  a  strong 
tendency  to  retract.  The  manner  of  applying  the  plaster  is  to 
have  it  nicely  spread  upon  strips  of  soft  leather  or  linen,  and 
upon  this  much  depends;  after  the  wound  has  ceased  to  bleed, 
and  the  skin  on  each  side  is  wiped  dry,  an  assistant  draws  the 
edges  into  accurate  contact,  and  the  surgeon  applii  s  the  plaster, 
previously  warmed  over  a  chafing  dish  of  coals,  first  on  one  side, 
and  waiting  till  it  adheres,  draws  it  with  moderate  force,  and  at- 
taches it  to  the  other.  Successive  strips  are  to  be  applied,  until 
the  wound  is  covered,  so  that  the  edges  may  be  kept  in  contact 
throughout  its  whole  length. 

In  cuts  of  the  lips  or  cheeks,  much  neatness  is  required,  as 
indeed  in  all  sutures ;  but  here  especially,  since  a  slight  irregularity 

*  I  have  drawn  two  figures,  one  to  fhew  the  proper  manner  of  putting  in  the 
pins,  the  other  to  %ew  a  very  common  error,  which  is,  often  as  in  li^.  3,  the  lower 
pin  is  put  in  a  little  above  the  red  part  of  the  lip,  a  couliderable  part  ot  which 
lails  to  be  re-united :  but  in  fig.  2,  1  have  ihiwn  the  lowtfi  pit:  tntro  laced  as  it 
fhould  be,  fluck  through  the  loweft  point  of  the  lip,  and  introduced  lint  io  as  to 
fecure  the  oppofition  of  the.loweit  points  of  the  cut  edges,  tor  on  that  chiefly  de- 
pends the  deformity  or  neatnefs  of  the  lcar. 


6  Of  Wounds  of  the  Skin. 

in  the  lip  is  a  great  deformity,  and  a  great  reproach  to  the  sur- 
geon. In  the  lip  we  can  have  no  security  but  from  the  firmest 
kind  of  suture  :  the  lip  hangs  loose,  and  is  quite  unsupported  on 
its  inner  surface  ;  it  is  verv  dilatable  ;  it  moves  with  the  slight- 
est motions  of  the  mouth  or  jaws;  or  it  is  so  strongly  retract- 
ed in  "laughter  and  other  emotions  by  the  muscles  of  the  cheek, 
that  it  must  be  particularly  well  secured.  Though  some  have 
pretended  to  re-unite  the  hare-lip  by  plasters,  I  know  that  even 
in  a  grown  person  nothing  will  secure  it  but  the  pin.  In  acci- 
dental cuts  we  operate  exactly  as  after  operations  for  hare-lip 
or  for  cancer.  We  take  the  pin,  fixed  in  the  instrument,  called 
porte-aiguille,  in  the  right  hand,  and  holding  the  edges  of  the 
lip  together  with  the  fingers  of  the  left,  transfix  both  lips  with 
the  pin,  at  points  exactly  opposite  to  each  other,  pushing  the  pin 
with  the  right  hand ;  and  resisting  and  managing  the  lips  with 
the  left  hand,  we  pass  two  pins*,  one  exactly  in  the  tip  of  the 
lip,  through  the  red  and  fleshy  part,  for  that  secures  the  even- 
ness and  just  form  of  the  lip,  and  another  through  the  middle 
of  the  lip,  and  then  twist  a  wax  thread  round  both  pins  firmly, 
but  gently,  in  the  form  of  a  figure  of  8f. 

The  pin  should  be  drawn  out  the  second  day  ;  they  are  usu- 
ally left  too  long,  and  the  tension  of  the  pins  occasions  a  suppu- 
ration, a  puckering  of  the  wound,  and  a  visible  scar.  Pins  are 
recommended  in  other  wounds  of  the  face,  but  are  in  no  case 
except  in  the  single  one  of  a  divided  lip,  equal  to  the  interrupt- 
ed suture.  Where  pins  are  used,  I  think  common  sewing 
needles,  or  those  used  by  glovers,  which  have  triangular  edges, 
are  in  all  cases  superior  to  the  gold  pins.  When  you  are  going 
to  use  the  interrupted  suture,  let  your  needles  be  smaller  and 
nicer  than  they  are  usually  made,  less  curved,  and  flat,  with 
two  very  fine  cutting  edges ;  let  your  threads  also  be  smaller 
than  they  are  commonly  used,  and  let  them  be  a  little  waxed  in 
order  to  flatten  them  and  unite  the  two  threads,  but  draw  them 
afterwards  through  your  fingers  dipped  in  oil,  in  order  to  make 
them  glide  through  the  flesh.  Allow  the  bleeding  to  cease  en- 
tirely :  if  it  do  not  stop,  use  an  astringent,  as  vinegar  and  water ; 
make  a  stitch  of  the  needle  at  each  angle  of  the  wound  ;  repeat 
them  one  for  each  inch  in  length  of  the  wound ;  draw  them  un- 

"  Three  pins  or  ftitches  will  be  generally  required :  as  many  muft  be  employed 
as  will  bring  the  parts  into  accurate  contact.     S. 

t  In  operating  for  the  hare-lip,  it  is  neceffary  in  the  firft  inftance  to  remove  all 
the  fkin  at  the  edge  of  the  cleft.  The  piece  of  fkin  taken  off  refembles  the  letter 
A  inverted.  Pins  or  needles  are  by  no  means  neceffary  for  this  operation  :  the 
interrupted  future  is  I  believe  in  more  general  ufe  :  it  is  the  method  I  have  uniform- 
ly feen  employed  by  others,  and  it  is  the  one  which  I  have  always  praclifed  with 
fiKcefs.    S. 


Of  deep  Muscular  Wounds.  7 

til  the  edges  are  brought  into  contact  ;  cross  each  intermediate 
space  with  a  strap  of  sticking-plaster  ;  over  the  whole  apply  a 
bandage,  if  one  can  be  adapted  to  the  part,  so  as  to  aid  in  keep- 
ing the  wounded  surfaces  in  contact. 

Although  the  lip,  nose,  or  any  other  part  be  almost  entirely 
cut  off,  if  there  be  the  smallest  portion  of  flesh  connecting  it  to 
the  general  system,  you  are  not  to  despair  of  re-uniting  it ;  ior 
this  purpose  you  will  retain  the  newly  divided  piece  in  its  natural 
situation,  by  the  means  above  pointed  out.  It  is  wonderful  how 
parts  will  re-unite  after  they  seem  to  be  irrecoverably  separated, 
and  deprived  of  any  adequate  supply  of  blood*. 

If  the  tongue  be  partly  cut  across,  as  by  falling  on  the  chin 
when  it  is  lolling  out,  or  by  being  caught  between  the  teeth, 
in  convulsions,  the  part  which  is  divided  may  be  joined  bv 
a  stitch  of  the  needle. 

SECTION    IV. 

Rules  for  the  Re-union  of  deep  Muscular  Wounds. 

In  deep  muscular  wounds  we  are  obliged  to  rely  principally 
upon  compresses  and  the  uniting  bandage,  for  stitches  can  re- 
tain the  edges  only  of  a  wound  in  contactf,  even  this  however  is 
of  use  ;  they  should  therefore  be  employed,  although  it  will  be 
frequently  necessary  to  cut  them  out,  in  consequence  of  the 
violent  inflammation  or  some  unfavourable  symptoms  which 
may  supervene  J.  But  you  are  to  recollect  that  you  do  not  sew 
such  woiands  with  the  expectation  that  the  divided  parts  will 
adhere,  but  if  you  can  keep  them  nearly  in  contact  for  24  hours 
or  a  little  more,  they  inflame,  they  are  thickened,  blood  and 
lymph  are  extravasated,  the  cut  muscles  adhere  to  the  parts  un- 
derneath, and  though  no  union  takes  place  between  themselves, 
they  cannot  retract.  By  this  alone  a  great  advantage  is  gained, 
for  if  you  allow  the  muscles  to  retract  while  they  are  bleeding 
and  moveable,  and  let  them  continue  so  till  the  wound  is  stiff 

*  Even  if  a  part  were  entirely  feparated,  if  called  to  the  cafe  immediately,  the 
furgeon  fhould  endeavour  to  re-unite  it.  Adhefion  may  take  place,  and  fhould  it 
not,  the  attempt  can  be  of  no  injury  to  the  patient.     S. 

t  This  point  is  well  illuftrated  by  the  cafe  of  a  foldier,  who  being  wounded  at 
the  Corps  de  Garde,  acrofs  the  fhoulder  through  the  belly  of  the  deltoid  mulcle, 
his  furgeon  fewed  the  wound  that  night  with  many  deep  ftitches  i  thefc  Mr.  Pi- 
brac  was  next  morning  obliged  to  cut  on  account  of  convulfions  of  the  arm,  which, 
ccafed  the  moment  he  had  done  fo. 

Memoires  de  Z'  Academic  de  Chirurgie. 

t  If  ftitches  are  ufed  at  all,  I  think  they  fhould  pafs  to  a  confiderable  depth,  ana 
fhould  they  caufe  convulfions  or  other  unfavourable  fymptoms,  they  fhould  be  im* 
mediately  cut  out.    S. 


8  Of  Complicated  Wounds. 

and  inflamed,  they  become  fixed  in  that  position,  and  will  con- 
sequently heal  with  a  gap;  and  besides  being  weakened  !>v  loss 
of  substance,  their  action  is  still  more  impeded  by  their  being  fixed 
to  the  skin  and  the  parts  beneath.  If  the  wound  then  be  broad, 
you  must  sew  it  with  such  stitches  as  its  size  and  the  mass  of 
parts  you  have  to  support  may  require,  aiding  your  ligatures 
with  plaster,  compresses  and  bandage.  But  it  the  wound  be 
exceedingly  deep,  as  that  made  by  the  stab  ot  a  sword,  or  of  a 
pike  or  bayonet,  voumust  not  think  ol  stitching  it,  for  the  mouth 
of  such  a  wound  bears  a  very  small  proportion  to  its  size  :  you 
squeeze  it,  wash  it,  and  trust  entirely  to  the  compresses,  one  of 
which  you  put  upon  the  mouth  of  the  wound,  and  should  the 
blade  have  passed  slantingly  along,  you  must  lay  a  long  compress 
*  wherever  you  think  by  means  of  it  you  can  put  the  sides  of  the 
wound  in  contact  with  each  other.  Gentle  pressure  is  here  pe- 
culiarly useful.     This  is  a  proper  case  for  the  uniting  bandage*. 

section  v. 

Rules  for  the  Re-union  of  Complicated  Wounds,  where  there  is 
a  Wounded  Artery  or  Fractured  Bone. 

In  wounds  in  which  large  arteries  are  divided,  the  first  thing 
to  be  attended  to  is  the  securing  of  the  bleeding  vessel,  by 
means  of  ligatures  ;  and  after  the  flow  of  blood  is  entirely 
stopped,  you  close  the  wound,  and  dress  it  as  above  directed  ; 
taking  care  to  leave  the  ligatures  hanging  out  at  its  most  depend- 
ing angle.  Complete  adhesion  cannot  be  here  expected,  as  a 
slight  suppuration  will  always  take  place  around  the  ligatures  ; 
but  if  the  cut  be  extensive,  adhesion  may  take  place  to  a  consi- 
derable, extent,  which  will  very  much  expedite  the  cure  :  the 
ligatures  may  be  easily  taken  away  in  a  few  days. 

When  the  bone  is  broken  or  cut,  still  we  pursue  our  great 
general  intention  of  re-uniting  the  divided  parts  ;  we  return  the 
bone  into  its  place  if  it  projected,  stitch  the  skin  over  it,  draw 
together  all  the  open  spaces  with  slips  of  adhesive  plaster,  and 
dress  the  wound  with  lint  moistened  with  camphorated  spirits  ; 
then  apply  a  roller,  with  moderate  firmness,  about  the  part,,  in 
order  to  ktep  ad  firm  ;  and  finally,  if  it  be  a  limb,  lav  it  as  you 
would  do  if  it  were  fracturedf.     The  great  object  to  be  kept 

*  Vide  Difcourfe  on  Bandages,  fig.  ir.  The  uniting  bandage  is  there  repre- 
fented  as  applied  to  the  forehead,  but  it  is  a  bandage  more  appropriated  to  the 
limbs  ur  body. 

f  This  fubject  is  treated  more  at  large  under  the  head  of  Compound  Fracture. 

—Which  lee.    S. 


,  t 


Of  complicated  Wounds,  9 

in  view,  is  to  put  the  divided  portions  into  contact,  and  to  re- 
tain them  in  that  position.  The  same  plan  is  to  be  pursued 
where  a  joint  is  laid  open,  even  though  the  integuments  should 
be  greatly  bruised  and  lacerated :  try  at  least  to  save  the  limb  ; 
the  attempt  can  do  no  harm*. 

But  there  is  one  case,  and  perhaps  one  only,  where  adhesion 
is  physically  impossible  ;  and  that  is  the  case  of  gun-shot 
wounds  ;  for  the  parts  are  not  hurt  and  lacerated  merely,  but  they 
are  so  bruised  by  the  ball  that  they  are  killed,  and  a  partial  gan- 
grene and  sloughing  must  precede  their  cure.  It  is  only  after 
the  sloughing,  and  during  the  granulation  of  the  wound,  that 
the  parts  can  adhere  ;  and  the  adhesion  does  not  take  place  at 
once,  but  slowly  and  successively.  But  we  have  every  mo- 
tive, especially  where  flaps  of  skin  or  muscle  are  torn  up  by 
shot  or  splinters,  to  bring  the  parts  closer  and  closer,  as  the 
sloughing  proceeds,  in  order  to  give  each  point,  as  it  resumes 
its  healthv  action,  a  chance  of  renewing  its  connexion  with  the 
sound  adjoining  parts;  and  thus  there  were  certain  cases,  where 
a  judicious  surgeon,  departing  from  the  established  rule,  will 
venture  to  put  a  stitch  in  even  a  gun-shot  wound,  drawing  up 
the  points  not  so  firmly  and  closely  as  in  other  cases,  not  with 
any  expectation  of  the  wound's  uniting  by  adhesion  at  those 
points  where  it  is  sewed,  but  with  the  design  of  merely  sup- 
porting a  flap,  in  order  to  preserve  it,  and  keeping  itneaih  in  that 
direction,  in  which  he  would  like  it  should  adhere  ;  for  it  does 
adhere  in  the  second  period  of  the  cure,  when  sloughing  is 
over,  and  the  parts  begin  to  re-uuite. 

Even  in  wounds  of  the  belly  and  breast,  it  is  adhesion  of 
the  parts  inwardly  wounded  which  saves  the  patient:  it  is  quiet, 
perfect  silence  and  composure,  and  the  natural  powers,  that 
bring  about  this  adhesion.  You  bring  the  lips  of  the  wound 
gently  and  softly  together,  and  retain  them  so:  you  wait  pa- 
tiently the  event  of  this  natural  process  :  you  can  do  little  to 
assist,  but  you  must  do  nothing  to  disturb  it.  Many  a  patient 
died,  in  consequence  of  the  older  surgeons  thrusting  lint  into 
the  wounds  of  the  large  cavities  :  and  even  now,  we  are  apt  to 
do  harm,  by  the  unmeaning  and  too  curious  probing  of  such 
wounds. 


*  When  the  knee  joint  has  suffered  compound  luxation,  it  forms  an  exception 
tn  this  rule.  Under  these  circumstances,  there  is  little  prospect  of  union  by  thr 
first  intention.  I  should  therefore  advise  the  amputation  of  the  limb,  for  feat 
the  patient  should  die  from  the  symptomatic  fever,  which  would  probably  ensue. 
Amputation,  indeed,  would  afford  no, great  chance  of  recovery,  as  a  vast  ma- 
jority of  those,  whose  limbs  are  taken  off  immediately  after  an  accident,  di<- 
For  this  reason,  among  others,  I  would  always  endeavour  to  save  a  patient  who 
had  a  compound  luxation  of  th»  ankle-joint.     S, 

B 


10  Of  cutting  out  the  Stitches. 

SECTION    VI. 

Of  cutting  out  the  Stitches. 

Adhesive  inflammation  is  attended  with  but  a  slight  degree 
of  fever,  pain,  swelling,  or  redness.  Adhesion  prevents  or 
stops  the  progress  of  inflammation  ;  for  as  it  was  the  divisioa 
of  the  parts  which  would  have  caused  it,  it  will  of  course  be 
prevented  by  their  re-union*.  As  every  part,  which  is  not  in 
contact,  must  inflame,  that  inflammation  may  extend  to  the 
parts  which  do  adhere  ;  so  one  point  left  thus  separate,  endan- 
gers the  whole,  for  adhesion  and  inflammatory  action,  to  any 
considerable  degree,  are  incompatible.  The  stitches,  if  they 
are  drawn  too  tight,  are  too  numerous,  or  made  with  too  coarse 
a  ligature,  will  cause  inflammation  :  this  will  endanger  the 
whole,  by  disposing  the  wound  to  burst  open  :  this  may  some- 
times be  prevented  by  timely  cutting  the  ligatures.  The  mo- 
ment you  observe  much  pain  or  swelling  in  the  wound,  a  sepa- 
ration of  its  lips,  the  stitches  tense,  and  the  points  where  they 
were  made  particularly  inflamed,  undo  your  bandages,  draw 
out  your  pins,  cut  your  ligatures,  and  take  away  every  thing- 
like  stricture  upon  the  wound.  These  prudent  measures  may 
abate  the  rising  inflammation,  and  prevent  the  total  separation 
of  the  skin.  But  should  the  inflammation  rise  still  higher,  and 
should  you  perceive  that  a  total  separation  and  turning  out  of 
the  wound  is  inevitable,  you  must  throw  all  loose,  put  a  large 
poultice  around  the  whole,  and  forsake,  without  hesitation,  all 
hopes  of  procuring  adhesion.  As  suppuration  will  now  come 
on,  after  it  is  completely  established,  and  the  inflammation  has 
subsided,  you  endeavour  again  to  bring  the  edges  of  the  wound 
together,  not  by  stitches,  but  by  sticking  plaster  and  bandage. 


SECTION    vil. 

Description  of  those  wounds  where  adhesion  is  not  easily  ob. 
tained,  and  of  the  accidentsj?y  which  it  is  hindered. 

A  wound  will  probably  not  adhere  where  its  edges  are  not 

*  Adhelion  arrefts  the  progrefs  of  inflammation  in  contiguous  furfaccs,  as  well 
as  in  wounds.  Thus  where  the  pleura  becomes  inflamed,  adlufion  takes  place 
between  it  and  the  part  with  which  it  is  in  contact ;  by  which  means  the  further 
progrefs  of  the  difeafe  is  prevented.  For  much  important  information  upon  the 
fubjed;  of  Adhefive  Inflammation,  fee  Hunter  on  the  Blood,  p.  277,  Burns  on 
Inflammation,  vol.  2.  p.  7- 


Of  Wounds.  11 

completely  opposed  to  each  other,  or  where  thev  have  been 
■•brought  together  with  difficulty,  and  consequently  the  parts 
put  upon  the  stretch,  where  there  is  a  necessity  for  many  and 
deep  stitches,  or  a  tight  bandage.  When  a  wound  is  deep,  it 
does  not  always  adhere.  It  there  be  a  foreign  body  in  it,  ad- 
hesion will  not  often  take  place  :  an  effusion  of  any  consider- 
able quantity  of  blood  has  likewise  the  same  effect.  A  ragged 
and  lacerated  wound,  one  made  by  the  crushing  of  great  stones, 
of  mill-wheels,  or  other  machinery,  the  bite  of  a  horse,  dog, 
or  other  animal,  can  not  easily  adhere  ;  because,  from  the  ir- 
regular laceration,  the  surlaces  will  not  correspond.  The 
manner  also  of  uniting  a  wound,  may  be  so  faulty  as  to  prevent 
its  adhesion;  for  if  it  is  left  still  bleeding  at  the  time  it  is  stitched, 
if  a  piece  of  the  skin  be  turned  inwards  when  it  is  sewtd,  if  a 
piece  of  bone,  quite  loose  and  detached  be  left  in  the  wound, 
if  the  stitches  be  too  frequent,  or  drawn  too  tight,  inflammation 
will  probably  take  place  to  so  great  a  degree  as  to  prevent  union. 
If,  m  addition  to  the  faults  abovementioned,  a  roller  be 
applied  too  firmly  around  the  limb,  the  whole  swells  the  first 
day,  the  stitches  inflame  the  second,  if  they  be  not  slackened 
or  cut,  they  burst  out  on  the  third,  and  extensive  suppuration 
ensues.  But  the  worst  case  ol  all  is,  when  stitches  are  impru- 
dently made  after  a  wound  has  already  become  inflamed  ;  for 
then,  instead  of  abating,  they  will  augment  the  inflammation. 

An  unhealthy  constitution  is  unfavourable  to  the  healing  of 
wounds  ;  but  under  this  head,  I  by  no  means  comprehend  a 
scrofulous  habit  of  body  ;  on  the  contrary  we  find,  that  in  such 
habits  a  clean  incision  heals  with  peculiar  ease  ;  but  if  a  man 
be  scorbutic,  syphilitic,  or  feverish,  ill  clothed,  exposed  to  cold 
and  moisture,  if  he  be  laid  in  a  foul  hospital,  prison-ship  or 
jail ;  if  he  be  a  prisoner  when  wounded,  depressed  in  spirit, 
weakened  in  bod}  ;  if  he  have  lived  long  in  an  unhealthy  camp, 
or  in  a  warm  climate ;  any  wounds  he  may  have  will  not  quick- 
ly unite  ;  or  if  they  have  adheretl  imperfectly,  they  inflame  and 
burst  out  again  the  moment  these  circumstances  affect  his  ge- 
neral health,  or  as  soon  as  he  is  attacked  with  fever,  dysentery, 
or  an  old  intermittent.  It  is  debility  which  causes  this  inflam- 
mation and  bursting  of  wounds  ;  and  it  is  debility,  either  ha- 
bitually or  suddenly  induced,  which  converts  wounds  into  ma- 
lignant sores. 

This  reminds  me  of  telling  you  in  the  last  place,  how  impor- 
tant it  is  to  procure  adhesion  in  the  very  first  moment  of  a 
wound.  A  speedy  adhesion  saves  pain  and  inflammation,  pre- 
vents suppuration,  waging  ol  flesh,  a  wide  scar,  and  all  the 
other  dcloi  mitit  s  and  distresses  of  an  ulcerating  wound  :  it  pre- 
vents more  serious  ill  consequences  than  pain  and  deformity,  it 


12  Of  Wounds, 

prevents  that  bursting  of  arteries  so  apt  to  happen  in  an  ulcera- 
ting sore,  or  that  oozing  of  blood  which  is  so  much  more  diffi- 
cult to  command  than  the  most  impetuous  bursting  of  sound 
arteries,  which  is  always  an  omen  of  something  still  worse  ap- 
proaching. The  speedy  adhesion  of  a  wound  prevents  sleepless 
nights,  diarrhoea,  ftvtr,  emaciation,  and  the  accession  of  the 
hospital  fever  or  hospital  sore.  You  do  not  know,  alter  a  bat- 
tle, how  soon  your  patient  may  be  thrown  into  some  foul  hospi- 
tal !  nay,  even  in  a  stationary  and  well  regulated  hospital,  your 
patient  may  be  seized  with  hospital  fever,  dysentery,  or  some 
other  disease.  If  you  once  get  the  adhesion  thoroughly  accom- 
plished before  any  such  misfortune  happen,  your  patitnt  is  in 
some  degree  safe  ;  if  you  neglect  the  first  moment  of  the  heal- 
ing of  the  sore  by  adhesion,  it  may  never  heal  ;  if  he  lie  but  a 
few  days  in  an  hospital  with  an  open  wound,  the  sore  is  follow- 
ed with  diarrhoea,  foul  tongue,  nausea,  and  thirst  ;  the  sore  de- 
generates, he  falls  into  a  fever  and  dies  ;  his  safety  and  his  life 
often  turn  upon  this  single  point  of  procuring  adhesion. 


DISCOURSE  II. 


OF  ILL  CONDITIONED  AND  COMPLICATED 
WOUNDS;  OF  ULCERS,  DRESSINGS,  AND 
BANDAGES. 


SECTION    I. 

Of  ill  conditioned  and  complicated  Wounds. 

A  HE  curing  of  ill  conditioned  wounds  is  a  wide  and  important 
department  of  Surgery  ;  for  under  this  class  we  must  reckon 
almost  all  wounds  which  do  not  immediately  adhere ;  all  com- 
plicated wounds,  in  which  gunshot  wounds  are  included,  and 
all  others,  in  which  extensive  suppurations  must  necessarily  take 
place,  or  the  part  mortifies.  Whenever,  therefore,  from  the 
nature  of  the  accident,  it  is  impossible  to  procure  adhesion,  your 
next  endeavour  should  be  to  bring  on  suppuration  ;  for  which 
purpose  you  must  have  recourse  to  warm  fomentations  and 


Of  ill  conditioned  and  complicated  Wounds.  I B 

poultices  frequently  renewed.  These  must  be  discontinued  as 
soon  as  the  suppuration  is  established,  for  after  that  the  relaxa- 
tion of  parts  which  they  induce,  is  highly  injurious.  After  pro- 
viding free  outlets  for  the  matter,  a  circumstance  to  w  hich  very 
particular  attention  is  to  be  paid,  dress  the  wound  for  a  few  days 
with  dry  lint  only*,  taking  care  to  apply  moderate,  regular  pres- 
sure, by  means  of  a  roller,  from  one  extremity  of  the  member 
to  the  other,  if  it  be  one  of  the  limbs  which  is  affected.  Should 
the  granulations  appear  pale  and  flabby ;  should  the  discharge 
of  matter  continue,  some  stimulant  application  will  be  necessary 
in  order  to  excite  the  parts  into  a  more  vigorous  action,  for 
these  are  the  effects  of  debility.  A  poultice  then  can  be  use- 
ful in  the  first  days  of  a  wound  only,  either  where  from  the  na- 
ture of  the  accident  it  is  impossible  to  procure  adhesion,  or 
where  it  has  been  vainly  attempted.  Even  in  the  case  of  a 
common  abscess,  though  we  have  no  application  so  soft  and 
pleasant,  so  effectual  in  relaxing  the  skin  and  promoting  suppu- 
ration, as  a  poultice,  as  soon  as  the  suppuration  is  perfected, 
and  the  abscess  is  optned,  the  continuing  the  poultice  (as  is  too 
often  done)  relaxes  the  part  and  increases  the  discharge.  Even 
in  this  case,  the  fairest  of  all  for  using  poultices,  we  employ  them 
but  for  a  time  and  for  a  purpose.  While  then  an  abscess  is 
forming  in  a  limb,  which  has  been  severely  injured  by  some  ac- 
cident, you  will  watch  it  with  incessant  care ;  for  an  abscess 
which  might  at  first  be  easily  cured,  olten  by  being  neglected 
goes  down  to  the  bone.  At  each  dressing  you  feel  carefully  all 
parts  of  the  limb,  you  allow  no  appearance  of  redness,  no  com-* 
plaint  of  pain,  no  feeling  of  softness  to  pass  unobserved.  Jin  a 
f  disease  like  this,  an  abscess  does  not  project  from  the  surface 
like  a  boil,  but  works  downward,  among  the  muscles,  long  be- 
fore the  part  becomes  red.  This  is  an  abscess  forming  in  the 
midst  of  a  great  mass  of  thickening  and  disease  ;  the  abscess  is 
often  the  flattest  part  of  the  limb  ;  and  when  you  feel  one  part 
sinking  below  the  general  level,  and  the  integuments  becoming 
thin;  when  your  fingers  sink  into  a  softish  hollow,  which  feels 
empty,  with  a  hard  and  knotty  border  surrounding  it,  you  may 
be  assured  the  abscess  is  formed.  Then  you  must  open  it,  lest 
the  matter  sink  deeper  among  the  parts  ;  you  never  make  a  large 
opening,  nor  cut  up  the  skin,  but  use,  in  place  of  the  broad 
shouldered  abscess  lancet,  a  small  bleeding  lancet.    Strike  deep  ; 

*  Where  the  difcharge  is  profufe,  prefled  fponge  is  better  than  lint,  as  it  more 
completely  abforbs  the  matter  as  faft  as  it  is  fecreted.  For  the  proper  local  reme- 
dies, vide  fection  on  Ulcers.  Attention  muft  at  the  fame  time  be  paid  to  the  ge- 
neral health  of  the  patient.  Bark,  wine  and  opium,  together  with  a  nourifhing 
diet,  unlefs  they  be  contra-indicated  by  inflammatory  fymptorm,  muft  be  prefcri- 
bed.  Without  attention  to  the  ftate  ef  the  fyftem,  and  the  exhibition  of  the  pro- 
per general  remedies,  topical  applications  will  be  of  little  avail.    S. 


14  Of  ill  conditioned  and  complicated  Wounds. 

open  the  abscess  thoroughly,  but  with  an  opening  so  small,  that 
you  need  press  out  the  matter  diligently  every  day.  You  will 
soon  discover  whether  your  opening  be  central,  and  whether 
the  exit  be  free  ;  you  introduce  your  probe,  and  feel  whether 
there  be  any  undermining  of  the  neighbouring  parts,  any  obli- 
quity of  the  abscess,  or  whether  the  abscess  be  of  such  extent 
that  a  counter  opening  is  required ;  you  squeeze  out  the  mat- 
ter gently,  but  with  perseverance ;  and  having  emptied  the  ab- 
scess, you  take  advantage  of  its  sides  being  put  together,  and 
endeavour  to  re-unite  them  ;  you  fit  your  compress  to  the  shape 
of  the  hollow,  you  make  it  of  soft  rolled  lint,  sometimes  you 
lay  on  the  lint  in  handfuls ;  you  roll  the  part  carefully,  and  with 
such  a  degree  of  firmness,  as  keeps  the  sides  of  the  abscess  in 
contact ;  though  you  may  not  procure  adhesion  at  the  first,  you 
reduce  the  size  of  the  cavity,  lessen  the  quantity  of  matter  in  a 
remarkable  degree,  and  in  the  course  of  time,  you  find  the  parts 
grow  firm,  and  the  sides  of  the  cavity  adhere. 

By  this  prudent  and  careful  proceeding,  you  gain  every  ob- 
ject ;  you  save  the  skin  from  being  further  destroyed,  and  the 
parts  within  from  being  further  drawn  into  disease  :  but  if  you 
neglect  this  opening,  the  muscles,  or  even  the  bones  suffer ;  if 
you  bpen  the  part  with  an  incision*,  especially  in  an  hospital, 
the  infection  comes  upon  the  sore,  and  the  patient  dies  ;  if  you 
open  it,  and  then  neglect  it,  the  openings  grow  fistulous,  and 
new  abscesses  are  formed.  By  opening  the  wrist  joint,  in  a 
case  of  gunshot  wound,  with  a  small  bleeding  lancet,  in  three 
points,  with  these  precautions,  I  have  saved  the  joint ;  whereas 
the  slightest  incisions,  in  the  same  wards  of  the  hospital  where 
this  man  lay,  burst  out  into  frightful  sores. 

You  must  learn  to  vary  your  practice  according  to  the  nature 
of  the  case,  and  especially  according  to  the  parts  concerned.  If 
the  suppuration  be  on  the  outside  of  the  fascia,  or  strong  bind- 
ing membrane  of  the  arm  or  thigh,  then  your  chief  business 
will  be  to  observe  the  rapidity  with  which  the  matter  will  under- 
mine the  skin  ;  for  the  fascia,  like  the  membranes  of  a  joint, 
excludes  the  inflammation,  and  resists  it ;  the  skin  only  is  in- 
flamed, its  cellular  substance  is  destroyed ;  the  skin,  by  being 


*  I  can  by  no  means  agree  to  the  propriety  of  the  practice  here  recommended 
by  Mr  Bell.  If  the  opening  be  not  fufficiently  extenfive  and  dependent  to  evacu- 
ate the  matter,  it  mult,  by  being  confined,  keep  the  fides  of  the  abfeefs  apart,  and 
thereby  prevent  their  union.  In  a  foul  hofpital  the  practice  may  be  proper,  but 
certainly  under  no  other  circumftances.  I  do  not  mean  that  an  extenfive  fup- 
puration  fhould  be  laid  open  from  one  end  to  the  other,  but  I  hold  no  principle 
in  Surgery  better  eftablifhed  than  that  openings  fufficiently  extenfive  for  the 
evacuation  of  matter  fliould  be  uniformly  made.  Where  matter  has  formed  under 
the  fafcia  of  the  thigh,  I  have  feen  the  beft  effects,  even  in  an  hofpital,  from  an  in- 
effion  three  or  fonr  inches  in  length.    S. 


Of  ill  conditioned  and  complicated  Wounds.  1 3 

thus  separated  from  the  fascia  beneath,  is  so  far  deprived  of  its 
nourishing  vessels,  that  it  is  hardly  alive  ;  it  is  thin,  livid,  rea- 
dy to  burst,  and  the  least  accident  will  make  it  slough,  and  fall 
off  in  gangrene.  If  the  inflammation  be  near  the  haunch,  the 
abscess  undermining  the  skin  of  the  thigh,  bursts  at  the  knee  ; 
if  in  the  leg,  th*  matter  follows  the  muscles  to  the  ancle  ;  if  in 
the  fore- arm,  it  bursts  cut  at  the  wrist  ;  and  some  degree  of 
management  is  necessary  to  give  a  free  vent  for  the  matter,  so 
as  to  preserve  the  skin. 

In  gunshot  wounds,  or  in  bruises  from  great  splinters  in  bat- 
tles at  sea,  you  will  most  particularly  observe  this  course  of  the 
matter  from  above  downwards.  It  is  from  this  working  of  the 
matter  to  distant  parts,  that  the  surgeon,  after  long  searching,  is 
often  disappointed  of  finding  the  ball,  and  feels  for  it  at  the 
point  most  distant  from  its  real  place.  If,  for  example,  a  man 
is  shot  with  a  musket  ball  in  the  haunch,  the  whole  thigh  will 
swell,  the  integuments  will  be  separated  from  the  thigh,  the 
muscles  too  (especially  if  the  wound  be  deep),  will  be,  as  it  were, 
dissected  by  the  matter  ;  the  chief  abscesses  will  burst  near  the 
knee,  the  6urgeon  will  search  there  in  vain  for  the  foreign  body ; 
the  patient  will  be  exhausted  by  pain  and  hectic  fever,  and 
when  he  dies  the  ball  will  be  found  lying  flattened  against  the 
haunch  bone,  or  sticking  about  the  trochanters  of  the  thigh 
bone  :  or  a  ball  passing  clean  through  the  fore-arm,  the  absces- 
ses, which  begin  to  form  about  the  elbow,  will  extend  down  to 
the  wrist;  or  the  elbow  being  only  bruised  and  slightly  wound- 
ed with  a  splinter,  the  abscess  which  forms  will  cover  the  whole 
of  the  bellies  of  the  extensor  muscles,  and  burst  at  last  near  the 
hanti*. 

Here,  then,  you  may  easily  perceive,  that  it  is  not  the  foreign 
body  lodged  in  the  wound,  nor  the  bruising  of  the  parts,  but 
the  matter  itself  following  the  tract  of  the  muscles  that  causes 
this  extensive  disease:  to  prevent  which,  you  must  attend  chief- 
ly to  these  things  ;  first,  To  open  the  abscess  early,  knowing 
what  destruction  the  confined  matter  will  make,  if  left  soaking 
its  way  downwards  through  the  cellular  substance  of  the  skin  : 
Secondly,  If  you  fiad  that  it  has  already  made  great  progress, 
and  that  the  abscess  points  below,  you  must  introduce  your 
long  probe,  pass  it  down  to  the  very  lowest  point,  and  cut  it 
out,  so  as  to  make  a  counter  opening,  by  which  the  abscess  will 
have  from  all  parts  a  free  discharge  :  Thirdly,  The  skip,  bc-in^ 
thus  weakened,  being  already  highly  inflamed,  unsupported  ' 
vessels  on  its  lower  surface,  its  cellular  substance  being  entirely 
destroyed  by  the  suppuration,  there  is  great  danger  lest  it  slough, 

*  But  this  takes  place  only  where  the  abfeef*  forms  under  the  fafcine  with  which 
the  liaibs  are  inveftcd.     S. 


16  Of  ill  conditioned  and  complicated  Wounds. 

with  a  total  loss  and  destruction  of  the  integuments  of  the  fore- 
arm, for  example  :  injections,  even  of  the  most  simple  kind,  are 
in  these  circumstances  so  dangerous,  that  if  unfortunately  a  sti- 
mulant one  be  thrown  in  under  such  an  extensive  surface 
of  diseased  skin,  it  will  gangrene  and  slough  ;  or  if,  under  pre- 
tence of  evacuating  the  matter  freely,  this  inflamed  skin  be  im- 
prudently cut  up  with  a  bistoury,  the  skin  must  inflame  to  the  ve- 
ry highest  point,  beyond  what  it  can  bear  ;  and  being  unsup- 
ported by  its  natural  vessels,  it  will  die  and  slough  off.  For 
these  reasons,  then,  you  never  are  to  use  the  knife  ;  you  are  on- 
ly to  make  fair  counter  openings  ;  when  you  push  through  your 
probe,  you  may  draw  after  it  a  small  and  fine  seton*  ;  but  even 
a  small  seton  is  too  irritating,  and  you  are  to  continue  it  only  a 
few  days  till  the  opening  be  thoroughly  established  ;  whenever 
you  are  sensible  that  the  course  of  the  matter  is  free,  you  must 
try  to  lessen  the  cavity,  and  to  keep  this  great  surface  of  the 
skin  in  contact  with  the  parts  below  by  a  gentle  roller  ;  but  the 
bandage  must  be  rolled  very  gently  and  very  equally,  and  your 
compression  must  be  made,  not  so  much  with  firm  bolsters,  as 
with  a  handful  of  plucked  lint  laid  over  the  whole ;  you  thus 
press  down  the  skin  that  is  already-  injured,  so  as  to  make  it 
re-unite,  and  you  oppose  a  barrier  to  the  further  progress  of  the 
suppuration. 

If  the  inflammation,  in  place  of  merely  undermining  the  skin, 
go  deep  among  the  muscles,  then  the  matter  finds  new  cavities 
and  hollows  to  lodge  in,  makes  new  and  crooked  passages  for 
itself  from  point  to  point ;  one  abscess  forms  after  another,  the 
suppurations  become  very  irregular  and  extensive,  and  this  is 
what  surgeons  incorrectly  call  a  fistulous  sore.  It  is  not  so, 
for  while  the  parts  continue  inflamed,  and  the  suppuration  good, 
the  disease,  however  extensive,  is  merely  an  irregular  abscess; 
and  what  is  chiefly  required  is  some  means  of  diminishing  the 
number  of  irregular  suppurations,  and  as  it  were  concentrating 
the  disease ;  for  the  surgeon  seeing  matter  confined,  the  open- 
ings narrow  and  irregular,  and  new  abscesses  forming  from 
day  to  day,  is  uncertain  which  way  the  matter  tends.  He 
knows  that  it  is  destroying  the  muscles,  and  fears  that  it  may  be 
spoiling  the  bones  ;  therefore  he  chooses  from  among  the  num- 
ber of  openings  those  two  which  seem  most  convenient  for  his 
purpose,  and  introduces  a  seton  from  the  one  to  the  other ;  or 
from  one  opening  he  pushes  down  his  long  steel  probe  to  the 
bottom  of  some  recent  suppuration,  cuts  out  the  probe,  and  so 

*  From  Mr.  Bell's  own  reafoning  I  fhould  apprehend  the  feton  would  be  alto- 
gether improper  :  a  piece  of  lint,  introduced  between  the  lips  of  the  wound, 
would  produce  all  the  good  effects  he  feems  to  expect  from  a  feton,  without  ma- 
terially increafing  the  inflammation,  already  too  great.     S. 


Of  ill  condi  tioned  and  complicated  W:  unds.  1 7 

draws*a  seton  through  the  most  central  part  of  the  suppurations. 
This  seton  is  not  to  be  removed  when  the  new  opening  is 
established  ;  it  is  to  serve  a  more  important  purpose,  it  is  to  lead 
the  pus  to  those  particular  openings  which  the  surgeon  has  cho- 
sen, it  is  to  prevent  the  matter  working  deep  among  the  mus- 
cles, and  draw  into  this  single  channel  the  matter  of  all  the  col- 
lateral abscesses.  The  seton  concentrates,  as  I  may  express  it, 
the  inflammation  and  suppuration,  and  brings  the  disease  into 
one  direct  line,  so  that  we  know  where  to  apply  our  compress 
and  roller  ;  we  so  narrow  the  passages,  and  lessen  the  quantity 
of  matter,  and  empty  the  collateral  abscesses,  by  the  operation 
of  this  seton,  compression,  ckc.  that  in  the  end  the  stton  may 
be  withdrawn;  but  more  commonly  a  fistula  proceeds  from 
some  foreign  body  lodged  deep,  a  ball,  a  piece  of  iron,  a  rag  of 
cloth,  or  a  spoiled  bone,  which  prevents  the  healing  of  the 
wound:  and  the  circumstances  and  peculiarities  of  a  fistula  are 
very  easily  and  naturally  deduced  from  this  cause  ;  for  where 
foreign  bodies  are  lodged  in  the  part,  and  of  course  foul  matter 
is  allowed  to  stagnate,  the  part  cannot  easily  heal;  but  the  pas- 
sages where  this  foreign  body  is  not  immediately  lodged,  reco- 
ver almost  their  natural  condition,  and  the  only  inflammation  is 
at  the  bottom  of  the  wound,  where  the  foreign  bodv  lies  irrita- 
ting and  supporting  the  flux  of  matter,  which  must  find  its  way 
out. 

Here  our  business  is  rather  to  exxke  inflammation,  and  pro- 
voke the  sensibility  of  the  parts*.  We  use  setonsand  injections 
in  this  case,  with  a  very  different,  and  much  bolder  design.  Se- 
tons  are  used  rough  and  large,  that  they  may  irritate  ;  they  are 
used  to  force  the  parts  into  a  state  of  suppuration,  and  to  destroy 
the  callosity.      They  are,  like   bougies,  oiten  loaded  with  irri- 


*  It  will  be  in  vain  to  attempt  the  cure  of  thefe  fiftulas  until  the  foreign  bodies 
are  removed  in  a  great  majority  of  inftances.  In  fome  rare  cafes  foreign  bodi"» 
become  enveloped  in  a  fac,  which  prevents  their  irritating  the  parts  in  which  they 
are  lodged;  but  this  is  fo  unufual  that  it  ouyht  never  to  be  calculated  upon,  and 
never  takes  place  I  believe  where  a  piece  of  dead  bone  or  cloth  is  the  initating 
fubftance.  Thefe  facs  moft  frequently  form  around  leaden  bullets.  After  the  fo- 
reign fubftancc  is  extracted,  fhould  the  fiftula  not  heal,  then  the  plan  of  treatment 
recommended  by  Mr.  Bell  may  be  adopted.  Where  thefe  extraneous  bodies  can- 
not be  removed,  all  that  the  furgeon  can  do  is  to  fupport  the  ftrength  of  the  pa- 
tient, prevent  the  formation  of  new  abfeeffes  as  far  as  is  in  his  power,  providf: 
dependent  openings  fo  that  the  matter  may  not  lodge,  and  bandage  the  part  fo 
that  it  cannot  burrow,  and  laftly,  examine  from  time  to  time  fo  a-,  to  extract  thefe 
fubftances  as  foon  as  poflible.  The  openings  may  be  prevented  from  doling  by 
introducing  prcfled  l'ponge.  When  a  hone  is  {battered  by  an  accident,  the 
furgeon  fhould  carefully  remove  all  the  fplinters  which  are  fo  nearly  detached  that 
they  cannot  live,  and  all  other  foreign  fubftances  which  he  can  difcover  without 
too  much  probing  and  examining  of  the  wound.  It  is  true  thei'e  things  may  be  dii- 
charged  in  the  fuppuration  which  muft  enfue,  but  it  is  like  wife  true  that  their  early 
removal  wiH  tend  very  materially  to  diminifh  tUat  fuppHrsrk)*.    S, 

c 


18  Of  ill  conditioned  and  complicated  Wounds. 

tating  medicines,  as  red  precipitate  mixed  with  basilicon,  and 
the  cords  are  drawn  through  every  day.  We  also  inject  a  fistu- 
la sometimes  with  barley  water,  merely  to  cleanse  it ;  but  often- 
er  with  tincture  of  mywh,  along  with  bark  decoctions,  to  correct 
a  putrid  ichor,  especially  when  there  are  corrupted  bones  in  the 
fistula,  or  where  blood  has  been  extravasated  through  the  cel- 
lular substance,  which  produces  always  very  foul  and  tetid  sup- 
purations. Sometimes  we  are  really  under  the  necessity  of 
using  escharotics,  as  injections  of  serugo  with  oil,  or  strong  stim- 
ulants, as  turpentine  diluted  into  the  form  of  a  balsam,  with  oil, 
basilicon  ointment,  or  balsamum  arcsei,  which  balsams  we  pour 
into  the  fistulous  holes  hot,  but  not  too  strong ;  yet  for  a  slightly 
stimulant  and  cleaning  "injection,  perhaps  there  is  not  a  better, 
than  rough  red  wine. 

Even  small  incisions  are  allowed  here.  We  lay  open  any 
smaller  fistula  in  order  to  get  a  more  direct  passage  for  ouiP 
seton  or  injection  into  the  greater  fistula,  or  to  enable  us  to  cure 
and  heal  up  some  collateral  fistula.  We  also  use  sometimes  a 
sponge  tent,  or  piece  of  gentian,  to  dilate  some  particular  open- 
ing, or  to  make  way  for  confined  matter ;  and  when,  by  care, 
and  various  inventions  and  practices,  we  have  obliterated  the- 
collateral  fistulas,  made  good  counter  openings,  procured  a  free 
vent  for  the  matter,  and  brought  the  whole  disease  into  one  di- 
rect line  ;  when,  lastly,  we  have  brought  the  tube  or  inward  sur- 
face of  the  great  fistula  into  the  state  of  an  inflamed,  active, 
and  granulated  sore,  and  have  converted  the  thin  ichor  into  a 
Weil  conditioned  pus,  we  endeavour,  with  our  rollers  and  com- 
presses, tore-unite  the  parts,  forming,  by  the  manner  of  rolling, 
what  the  old  surgeons  called  their  Uniting  and  Expulsive  Ban- 
dage. 

Wounds  with  collections  of  matter  round  a  joint,  are  the* 
most  afflicting  of  any ;  the  matter  is  resisted  by  the  capsule, 
and  makes  its  way  round  the  joint,  among  the  loose  cellular 
substance ;  it  finds  out  the  weak  parts,  as  the  axilla  or  ham,  and 
works  towards  them,  and  often  it  draws  the  acromion  process 
of  the  scapula,  or  the  olecranon  of  the  ulna,  or  any  other  pro- 
jecting bone,  into  disease.  The  joint  then  becomes  stiffened 
and  deformed,  the  integuments  swell  round  it ;  in  some  parts 
abscess  forms,  in  others  the  skin  is  vvondt  rfully  thickened ; 
there  is  all  the  appearance  of  white  swelling,  but  the  cavity  of 
the  joint  itself  is  not  affected,  though  at  last,  if  neglected,  the 
disease  penetrates  into  the  cavity,  and  the  true  white  swelling, 
or  disease  of  the  joint,  is  produced.  When  the  shoulder  or 
knee  is  thus  massed  by  inflammation,  hardened,  as  it  were,  in- 
tg  a  cartilaginous  knot,  and  perforated  at  all  points  with  fistulous 


Of  ill  conditioned  and  complicated  Wounds.  19 

sores,  the  ligaments  of  the  joint  are  thickened,  its  motions  are 
lost,  and  even  the  partial  cure  by  a  stiff  joint,  or  Anchylosis,  is 
hardly  to  be  obtained.     The  agonizing  pain  and  want  of  rest, 
the  diarrhoea,  and  hectic  fever,  which  are  inseparable  from  this 
degree  of  irritation,  often  destroy  the  patient,  or  hurry  us  on  to 
amputation.     But  while  the  diarrhcea  and  pain  can  be  modera- 
ted, while  the  strength  lasts,  you  should  try  to  cure  the  disease 
bv  varving  those  practices  which  I  have  just  mentioned.     You 
should  be  careful  not  to  relax  the  parts,  nor  hurt  the  little  vigour 
that  is  left  in  them,  by  the  application  of  poultices  ;  you  should 
remember,  that  the  skin  covering  such  a  joint  is  much  insulated, 
and  tends  greatly  to  inflame,   and  therefore  you  should  be  cau- 
tious in  using  injections ;  you  should  be  well  assured  that  the 
parts  are  really  fistulous   before  you  inject,  and  you  should  be 
the  more  anxious  and  prudent,  because  the  joint  itself  may  be 
affected,  and  you  may  be  driving  a  very  irritating  injection  into 
the  cavity  of  a  diseased  joint;*  nevertheless,  cleansing,  or  even 
stimulant  injections,  barley  water,  diluted  tinctures,  or  wine,  I 
do  not  condemn.     You  should  be  careful  to   watch  abscesses, 
and  prevent  their  extension,  by  small   and  frequent  openings 
with  the  lancet;  perhaps  it  may  be  right  to  use  a  seton,  in  order 
to  procure  a  free  drain  for  the  matter.     You  may  occasionally 
enlarge  one  fistulous  hole,  in  order  to  heal  up  two  or  three  colla- 
teral holes  depending  on  it.     You  should  use  a  poultice  only 
after  an  incision,  when  the  parts  are  irritated,  and  must  be  ap- 
peased ;  a  fomentation  you  will  use  often,  but  you  should  make 
it  hot  and  stimulant,  and  continue  it  but  for  a  short  while  ;  you 
should  support  the  joint  with  compresses,  or  rather  puffy  cush- 
ions of  lint,  and  a  gentle  roller  ;  but  be  fearful  of  tents,  which 
both  irritate  the  parts  and  confine  the  matter,  rather  enlarge  the 
fistulas  with  the  knife.     If  by  a  shot,  or  other  wound,  the  bone 
be  crushed,  you  easily  discover  it  at  first,  but  not  perhaps  the 
whole  extent  of  the  injury.    If  in  a  scrophulous  boy,  the  acromion, 
or  the  sternum,  or  any  other  bone,  be  spoiled  by  suppuration,  you 
know  it  by  the  black  and  peculiarly  fetid  discharge  ;•  you  feel  it 
with  the  probe  through  the  many  fistulous  openings  which  run 
along  the  ridge  of  the  bone  ;  a  man  of  experience  learns  even 
to  know  by  the  eye  this  state  of  the  sore  ;  and,  if  there  be  such 
a  diseased  bpne,  added  to  the  other  disorders,  and  if  the  bone 
be  projecting  at  one  end,  you  shake  it  from  day  to  day  till  you 
get  it  out.     Or  if  diseased  integuments  cover  the  carious  bone, 
having  fistulous  holes  from  point  to  point,  you  take  your  round 
edged  scalpel  and  lay  the  openings  all  into  one,  and  take  away 
the  diseased  bone.      Far  from  sparing  the  integuments,  you 

*  Injections  of  any  kind  would  be  highly  improper  where  there  was  a  poffibility 
«f  their  getting  into  the  cavity  of  the  joint.    S. 


Of  Ulcers. 

,iou!d  open  them  freely  ;  you  will  find  them  almost  insensible, 
cartilaginous  like  the  tube  of  a  fistula,  not  bleeding  when  cut,  but 
rather  needing  an  incision  to  excite  them,  and  especially  need- 
ing to  be  delivered  of  the  diseased  bone,  before  they  can  enter 
again  into  a  healthy  action,  and  granulate  or  unite. 

SECTION    II. 

Of  Ulcers. 

When  in  place  of  a  deep  and  bruised  wound,  you  have  a  flat 
and  superficial  wound,  it  often  degenerates  into  a  sore;  and  the 
methods  by  which  the  cure  of  such  sore  or  ulcer  is  attempted 
are  very   generally   known.       Occasionally,    a    sore    may  be 
wrapped  up  in  a  poultice,  or  soaked  in  a  stimulant  fomentation 
to  cleanse  the  ulcer,  or  to  abate  any  pain  or  inflammation  which 
our  medicines  may  have  raised  ;  but  a  continued  use  of  com- 
mon poultice,  of  carrot  poultice,  of  stale  beer  poultice,  or  any 
other,  serves  rather  to  relax  and  hurt  the  part.     I  believe,  that 
very  generally  the  cure  depends  on  the  prudent  use  of  astrin- 
gents, escharotics,  and  caustics,  which  must  be  changed  accord- 
ing to  the  condition  of  the  parts,  and  most  especially  it  depends, 
on  perfect  cleanliness  and  a  firm  bandage.     If  the  sore  be  going 
slowly  but  regularly  on,  it  requires  only  such  slightly  stimulant 
ointments  as  Turner's  cerate,  or  unguentum  tutise,  or  some  other 
ointment  made  with  zinc.     If  it  be  red  and  fresh  granulating,  let 
it  be  dressed  with  dry  lint  in  the  basin  of  the  ulcer,  and  straps  of 
ointment  round  the    edge.     If  the  action  of  the   parts  flags  at 
times,  and  the  sore  looks  gleety  and  pale,  sharpen  the  ointment 
by  adding  a  little  red  precipitate  to  it,  or  aerugo,  or  a  little  dried 
alum.     If  the  edges  are  quite  callous,  they  must  either  be  touch- 
ed with  caustic  daily,  or  pared  with  the  knife  :  for  if  this  be  not 
done,  the  edge  of  the  skin  being  by  this  callosity  disengaged 
from  the  soft  parts,  shrinks  and  wastes.     If  the  sore  be  flabby, 
with  a  profuse  discharge,  sharpen  your  ointment  by  adding  to 
it  some  spirits  of  turpentine  ;  the  sore  will  often  be  so  insensible 
as  to  require  to  be  fairly  powdered  with  pure  precipitate.     If  at 
any  time  these  processes  for  stimulating  a  sore  have  been  too 
suddenly  entered  upon,  or  too  harshly  followed  up,  so  as  to  ex- 
cite inflammation,  you  must  apply  a  poultice,  or  rather  a  warm 
fomentation  of  camomile  flowers,  with  crude  sal-ammoniac,  till 
you  restore  the  ulcer  to  a  quiet  and  easy  condition. 

The  most  tedious  and  persevering  ulcers  are  those  which 
arise  from  habitual  debility ;  such  are  scrophulous  and  constitu- 
tional sores.  The  most  destructive  and  horrible  ulcers  are 
those  whUh  arise  from  some  poison  infused  into  the  system,  de- 


Of  Ulcers.  21 

stroying  the  temperament  and  living  powers  in  the  parts  ;  such 
as  the  cancerous  or  venereal  poisons*.  The  ulcers  which  are 
the  most  in  danger  of  becoming  gangrenous,  are  those  where 
the  vis  vitas  of  the  whole  constitution,  or  of  the  particular  part, 
is  destroyed  ;  as  in  dropsy. 

Of  the  ulcers  produced  by  local  debility,  there  are  chiefly 
two  kinds,  first,  That  which  may  happen  to  any  part  of  the  bo- 
dy where,  in  consequence  of  a  wound,  violent  inflammation  has 
ensued,  carrying  the  excitement  to  that  height,  which  the  de- 
bilitated constitution  of  the  part  is  unable  to  bear.  Then  the 
parts  become  flaccid,  and  run  into  ulcer,  which  is  to  be  cured 
by  exciting  thena,  chiefly  by  those  topical  applications  which  I 
have  just  mentioned  :  or,  secondly,  A  local  ulcer  may  arise 
from  that  peculiar  weakness  of  the  lower  extremities,  of  which 
we  have  so  many  proofs  ;  for  it  is  there  that  leucophlegmatic 
swellings,  varices,  ulcers,  and  all  the  earliest  marks  of  consti- 
tutional debility  first  appear. 

Of  these  ulcers,  that  which  is  in  a  manner  peculiar  to  the  low- 
er extremities,  is  by  far  the  most  frequent.  The  cause  of  this 
weakness  in  the  lower  extremities,  is  their  dependent  posture  ; 
and  therefore  these  ulcers  are  to  be  cured  by  keeping  the  limb  in 
a  horizontal  position,  on  a  level  with  the  body.  Uniform  pres- 
sure, by  means  of  straps  of  sticking-plaster,  and  bandagef, 
must  at  the  same  time  be  applied.  For  this  purpose  after  the 
straps  are  drawn  tightly  around  the  limb,  it  must  be  firmly  rol- 
led from  the  toes  upwards.  In  warm  weather  cold  water 
pumped  upon  the  limb,  will  be  of  great  advantage  in  expedit- 
ing the  curej. 

You  will  commonly  find  the  general  fascia  or  tendinous 
sheath  which  covers  the  muscles  much  concerned  in  ulcer  ;  and 
I  am  persuaded  that  the  unyielding  nature  of  this  part,  more 
frequently  than  any  other  cause,  protracts  the  cure.  An  ulcer 
seldom  penetrates  deeper  than  the  skin,  it  is  seldom  able  en- 
tirely to  perforate  the  fascia;  it  is  the  ill  condition  of  this  insen- 
sible part  that  makes  a  sore  continue  throwing  off  sloughs  for 

•  When  ulcers  are  caufed  by  conftitutional  difeafes,  it  is  evidently  vain  to  at- 
tempt their  cure  until  the  general  dilorder  is  removed.  After  this  has  been  effect- 
ed they  are  to  be  treated  as  above  directed.     S. 

f  Vide  Difcourfe  on  Bandages. 

\  Ulcers  of  the  lower  extremities  are  fometimes  caufed  by  varicofe  veins,  and 
cannot  be  cured  until  the  caufe  is  removed.  The  operation  is  very  fimple,  dif- 
fe<5t  down  and  tie  the  vein  with  two  ligatures,  and  divide  it  between  them,  as  you 
would  do  an  artery  when  perfoming  the  operation  for  Aneurifm.  Trifling  as  this 
operation  is  in  appearance,  death  has  been  caufed  by  it  in  three  inftances,  one  of 
which,  a  patient  of  Mr.  A.  Cooper,  of  London,  1  examined.  The  internal  furface 
of  the  vein  appeared  inflamed,  as  well  as  1  recollect.  1  have  frequently  ftcn  ulcers 
improved  by  powdering  them  with  prepared  chalk,  powdered  rhubarb,  &c.  and 
then  applying  the  flicking  plaftcr  and  bandage,  as  recommended  by  Mr.  Home. 
The  beft  adhefive  plaftcr  is  that  recommended  in  the  note  *  page  4.  S. 


22  Of  Ulcers. 

months,  and  spreading  continually  ;  for  this  tendinous  sheath- 
which  lies  under  the  skin  being  dead,  deprives  the  skin  of  nou- 
rishment, by  destroying  the  intermediate  vessels  ;  the  skin  can- 
not close  over  a  part  which  is  dead,  any  more  than  flesh  can 
close  over  a  carious  bone  ;  nor  can  it  continue  sound  at  its 
edges,  since  its  edges  lie  over  the  dead  fascia,  unconnected  with 
it,  and  no  longer  nourished  by  vessels  :  the  skin  thus  shrinks 
from  a  part  with  which  it  can  hold  no  connection,  and  the  in- 
flammation and  the  matter  working  backwards  in  every  direc- 
tion, destroy  more  and  more  the  cellular  substance  which  lies 
betwixt  the  fascia  and  the  skin.  This  I  know  is  the  condition 
of  most  of  those  sailors'  ulcers  and  hospital  sores  which  I  have 
seen.  What  can  a  sprinkling  of  precipitate,  or  of  some  drug 
still  more  insignificant,  do  in  such  a  disease  ?  The  fascia  when 
once  brought  into  this  condition,  is  like  a  diseased  bone,  its  con- 
nections are  strong,  it  does  not  slough  off  soon,  but  keeps  its 
place  ;  the  filthy,  yellow,  thick,  and  mucous-like  matter  of  such 
an  extensive  ulcer,  is  produced  by  the  gradual  melting  down  of 
this  fascia.  Upon  removing  this  cream-like  substance  from  the 
surface  of  a  deep  ulcer,  we  see  the  fascia  covering  the  bottom 
like  a  sheet  of  soaked  shamoy  leather  ;  with  such  a  bottom  as 
this  the  ulcer  can  never  heal,  the  fascia  itself  is  dead,  and  will 
never  recover;  it  sloughs  off  more  slowly  than  even  a  diseased 
cartilage  or  bone.  Now  I  know  that  this  is  often  the  impedi- 
ment to  the  healing  of  great  ulcers ;  that  the  ulcers  is  perpetuat- 
ed only  from  this  diseased  and  yet  unyielding  state  of  the  fascia, 
and  this  has  been  the  occasion  of  many  losing  their  legs.  The 
habit  which  first  produces  such  an  ulcer  is  very  bad  ;  the  ulcer 
itself,  which  extends  so  as  to  uncover  the  fascia  in  this  manner, 
cannot  be  easily  cured,  although  the  fascia  were  cut  away  ;  but 
while  it  is  left  the  ulcer  cannot  heal ;  you  must  therefore  learn 
to  pare  and  clip  the  fascia  ;  and  it  will  be  some  encouragement 
to  you  to  know  that  I  have  often  cut  it  up  with  the  knife,  then 
pared  the  flaps  with  scissors,  cleared  the  leg  of  it  in  a  few  daysj 
and  brought  the  ulcer  very  suddenly  into  a  healthy  and  granu- 
lating state. 

When  ulcers  are  long  neglected,  the  worms  which  breed 
in  them  give  a  dreadful  appearance  to  the  disease.*  These 
vermine  are  not  the  only  ill  consequences  of  uncleanliness, 
for  without  any  other  cause  that  we  can  perceive,  they 
produce  the  most  extraordinary  ulcers.  I  subjoin  M'Gilli- 
vray's  case  as  an  example  the  best  calculated  to  explain 
.this  position  ;  for  his  wound  was  extremely  small,  the  ulcer 
which  followed  was  very  singular,  both  in  extent  and  appear. 

•  Thefe  worms  may  be  killed  by  warning  the  fore  with  the  jtrice  »f  the  lexvtV 
of  green  elder.     (Sambncus  Nigra  of  Linn.)    S. 


Of  Ulcers.  23 

ance,  and  was  finally  cured,  rather  by  care  and  cleanliness  than 
by  surgery.  Yet  what  is  surgery  in  this  case  but  cleanliness  and 
©are  ? 

This  man  had  been  wounded  on  the  Continent,  by  a  ball 
which  had  entered  under  the  clavicle  and  passed  out  behind. 
The  great  blood  vessels  had  escaped,  but  he  lost  a  considerable 
quantity  of  blood  from  the  small  arteries,  which. were  divided 
by  the  ball.  After  this  he  was  thrown  into  a  French  prison, 
where  he  endured  every  sort  ol  misery  for  two  years  and  eight 
months,  by  which  the  wounded  part  was  brought  into  the 
wretched  condition  in  which  it  was  when  I  saw  it.  In  winter 
he  suffered  extreme  cold;  he  lived  on  bread  and  water  only; 
and  of  the  black  bread  which  he  got,  his  allowance  was  but  one 
pound  a-day ;  no  surgery,  no  opportunity  of  cleanliness,  no  care. 
After  his  health  had  been  injured  by  cold  and  hunger,  the  heat  of 
summer,  in  a  close  wooded  country, corrupted  the  skin,  and  cover- 
ed his  shoulder  with  this  terrible  ulcer ;  half  a  year  had  elapsed 
from  the  time  of  his  being  wounded  before  the  surrounding  parts 
began  to  degenerate  into  this  very  singular  sore. 

The  sore  never  appeared  to  heal  during  the  heat  of  summer. 
The  skin  all  around  both  wounds  (and  to  great  extent),   grew 
livid  and  very  dark  coloured,  then  broke  out  into  white  pim- 
ples ;  the  pimples  afterwards  burst,  and  discharged  imperfectly 
a  white  viscid  matter;  two  or  three  pimples  ran  together  into 
one,  and  formed  a  sore  ;  then  a  scab  covered  that  sore,  confined 
the  matter,  made  the  inflammation  spread,  and  comprehend 
other  pustules ;  these,  again,  were  in  their  turn  closed  up,  the 
skin  was  undermined  by  successive  pustules  uniting;  from  pus- 
tules they  became  abscesses,  and   from  trivial  abscesses,  deep 
inflamed  sores.     During  the  progress  of  this  ulcer,  the  fcetor  of 
the  matter  was  such,  that  the  whole  prison  was  infected  with  it. 
The  poor  man  could  indeed  get  his  sore  washed  with  water, 
but  no  diligence  could  mend  his  condition;  the  fcetor  was  quite 
sickening  and  oppressive  to  himself;  the  ulcer  spread  first  iound 
the  wound  in  the  breast,  then  round  the  back  over  the  whole 
skin,  which  covers  the  shoulder  joint,  then  over  the  scapula, 
then  up  the  neck,  and  down  the  whole  side  ;  the  skin  became  re- 
markably livid,  every  where  greatly  thickened:  in  one  place, 
hard  and  callous,  in  another,  soft  and  boggy,  as  if  there  were 
matter  under  it,  although  there  was  none ;  in  one  place  an  ab- 
scess was  forming,  near  that  was  another  abscess  entirely  ripe, 
and  close  to  that  another  burst,  and  discharging  yellow,  very 
viscid,  and  mucous-like  pus,  which  undermined  and  destroyed 
the  skin.     These  various  abscesses,  in  all  stages  of  progress 
(like  ripe  and  unripe  fruit  on  one  branch),  worked,  not  super- 
ficially, but  deeply  among  the  cellular  substances,,  and  the  whole 


2*  Of  Ulcers, 

skin  was  puffed  up ;  you  might  have  felt  the  matter  in  these  ab* 
scesses  fully  a  month  before  they  burst ;  and  while  they  were 
working  under  the  skin,  the  veins  were  eroded,  and  the  blood 
burst  out,  sometimes  so  freely  as  to  bleed  like  the  vein  of  the 
arm.  He  frequently  bled  to  the  amount  of  two  pounds  at 
once,  and  much  of  the  blood  was,  at  the  same  time,  driven  un- 
der the  skin,  by  which  there  was  mixed  with  the  dark  red  of 
this  chronic  inflammation  the  blackness  of  echymosis  ;  and 
along  with  the  hardness  and  callosity  of  inflamed  skin,  there 
was  from  point  to  point  a  pulpy  feeling,  as  if  of  anasarca, 
echymosis,  and  abscess,  united.  There  were  besides  two  or 
three  flat,  thrombus-like  tumours,  fully  three  inches  in  diameter, 
which  when  pricked  with  the  lancet  emitted  only  blood. 

This  disease  being  merely  a  corruption  of  the  skin,  arising  at 
first  from  his  dirty  and  miserable  situation,  and  perpetuated  by 
one  little  abscess  after  another  undermining  and  destroying  the 
skin  ;  the  plan  which  I  laid  down  for  curing  him  was  this :  I 
ordered  him  the  warm  bath,  gave  him  a  purge,  and  put  him  on 
good  diet,  with  a  little  wine ;  I  directed  the  warm  bath  to  be 
repeated  three  times  a  week,  to  support  a  soft  and  pleasant  state 
of  the  skin ;  and  a  fomentation  of  camomile  decoction,  crude 
sal-ammoniac,  and  a  little  spirits  to  animate  the  skin,  was  appli- 
ed to  the  shoulder  for  one  hour  every  morning  and  evening. 
The  chief  point  was  to  manage  the  little  abscesses  and  throm- 
buses  so  as  to  prevent  their  undermining  the  skin.  I  opened 
two  or  three  with  the  knife,  and  taught  his  dresser  how  to  cut 
each  irregular  abscess  as  it  formed,  down  to  the  bottom,  with  a 
direct  incision,  till  he  reached  the  sound  flesh.  Each  abscess 
was  accordingly  cut  before  it  was  fully  formed,  with  the  knife, 
if  large,  (as  some  of  them  were  three  inches  long),  and  with 
the  lancet,  if  small.  The  incisions  were  not  made  in  what  may 
properly  be  called  an  abscess,  but  through  a  piece  of  diseased, 
spongy,  and  suppurating  skin.  The  matter  and  blood  were  thus 
prevented  from  undermining  the  skin ;  the  inflammation  was 
drawn  away  from  the  swelled  parts  towards  those  occasional 
incisions,  which  became  then,  as  it  were,  the  centres  to  their 
own  proportion  of  the  disease,  and  each  scarification  was  filled 
with  a  strong  mercurial  ointment,  rubbed  in  very  thoroughly 
witll  a  hair  pencil.  The  consequence  wae,  that  each  incision 
being  stimulated  into  a  right  and  healthy  suppuration,  was  made 
to  relieve  the  adjoining  skin  before  it  was  permitted  to  heal. 
By  these  practices,  varied  according  to  the  circumstances,  this 
stra  nge  disease  was  entirely  cured ;  it  had  continued  two  years 
and  nine  months  ;  but  by  persevering  in  this  plan,  especially  in 
respect  of  the  scarification,  (which  was  indeed  a  daily  and  se- 


■ 


I 


P.  '15. 


i 


'%. 


JOINEE 
A    BOY  o£  the  TRIUMPH. 


Of  the  Hospital  Sore  or  Gangrene.  25 

vere  operation)  he  recovered  perfectly  in  six  weeks.  Even  the 
dark  colour  of  the  skin  almost  disappeared,  and  it  became  soft, 
pliable  and  clean. 

SECTION    III. 

Of  Hospital  Sore  or  Gangrene- 

I  do  not  regard  hospital  sore  as  a  mere  ulcer,  to  be  treated 
like  other  common  ulcers,  but  as  a  general  affection  of  the  sys- 
tem, a  mortal  disease  ;  for  when  it  rages  in  a  great  hospital  it  is 
like  a  plague  ;  few  who  are  seized  with  it  can  escape. 

There  is  no  hospital,  howtver  small,  airy,  or  well  regulated, 
where  this  epidemic  ulcer  is  not  to  be  found  at  times  ;  and  then 
no  operation  dare  be  performed  !  every  cure  stands  still  !  every 
wound  becomes  a  sore,  and  every  sore  is  apt  to  run  into  gan- 
grene :  but  in  great  hospitals  especially,  it  prevails  and  is  a  real 
gangrene  :  in  the  Hospital  Dieu  of  Paris  its  ravages  continued 
for  ttfo  hundred  years,  until  that  hospital  was  reformed  by  the 
present  government  of  France*. 

Nothing,  perhaps,  will  contribute  so  much  to  your  under- 
standing this  disease,  as  a  plain  description  of  it  in  an  indivi- 
dual case. 

A  boy,  by  the  name  of  Joiner,  belonging  to  the  Triumph, 
whose  ulcer  I  have  drawn,  received  but  a  very  slight  and  super- 
ficial wound,  and  for  some  time  after  the  battle  he  continued  in 
health,  and  the  wound  healed  rapidly.  But  while  it  was  to  all 
appearance  florid  and  healthy,  with  no  threatening  of  ulceration, 
the  boy  in  full  spirits  and  strength,  walking  about  on  crutches, 
guilty  of  no  irregularity,  it  b°gan  to  look  ill  ;  a  sure  presage  of 
some  change  of  health. 

There  came  on  a  cough,  with  symptoms  of  a  common  cold, 
which  he  imputed  to  his  bed  being  placed  near  a  door,  lately 
open  and  now  shut,  but  not  walled  up  ;  then  his  health  failed, 
his  spirits  became  quite  oppressed  ;  he  had  occasional  attacks 
of  fever,  frequent  vomiting,  and  a  continual  loathing  of  food. 
With  these  slight  and  seemingly  unimportant  symptoms  (but 
the  tendency  of  such  symptoms  when  they  appear  in  a  foul  hos- 
pital is  easily  understood),  his  sore,  which  was  no  bigger  than 
the  palm  of  the  hand,  became  in  two  days  as  big  as  the  crown 
of  a  hat.  The  whole  skin  of  the  thigh  was  destroyed,  the  mus- 
cles were  stripped  of  skin  and  fascia  from  the  hip  to  the  knee, 

*  When  I  was  in  Paris  I  was  agreeably  furprifed  by  the  cleanlinefs  and  regula- 
rity of  this  Hofpital,  afti  r  having  heard  fd  much  "f  i'-  filthy  and  crow 

1) 


26  Of  the  Hospital  Sore  or  Gangrene. 

the  trochanter  was  almost  laid  bpre,  the  hamstring  muscles  ex- 
posed to  a  considerable  extent,  and  all  the  muscles  of  the  thigh 
dissected  in  a  manner  which  no  drawing  can  express. 

While  these  ulcers  made  their  dreadful  progress  in  any  of 
the  wounded,  I  could  observe  them  pass  through  the  several 
stages,  first  of  inflammation,  then  of  insensibility  and  gangrene, 
and  then  of  renewed  pain  and  sensibility.  First,  when  the 
health  is  affected,  the  patient  languishes  for  a  few  days,  and  the 
sore  inflames  ;  then  come  vomitings,  diarrhoea,  and  a  distinct 
fever,  and  the  disease  seizes  plainly  upon  the  wounded  part.  In 
its  first  stage  the  wound  swells,  the  skin  retracts,  wastes,  has  a 
dark  erysipelatous  redness  verging  to  black,  the  cellular  mem- 
brane is  melted  down  into  a  fetid  mucus,  and  the  fascia  is  ex- 
posed. But  in  the  second  stage,  the  fascia  and  skin  unable  to 
bear  their  inflammation,  and  deprived  of  mutual  support,  be- 
come black,  fetid,  soft,  and  fall  into  perfect  gangrene  ;  yet  there 
are  no  vesicles,  and  the  mortification  is  confined  within  the  ca- 
vity of  the  sore.  This  is  the  stage  of  insensibility ;  the  parts 
within  are  covered  and  defended  with  a  perfect  slough,  which 
no  medicine  can  penetrate,  on  which  no  applications  can  make 
any  impression;  and  stimulants  are  used,  without  pain,  of  such 
a  hot  and  fiery  nature,  as  none  but  dead  parts  could  resist  :  but 
when  these  sloughs  open  in  the  natural  course  of  the  disease, 
and  the  living  parts  are  exposed,  and  the  medicines  begin  to 
make  an  impression,  it  is  imagined  that  these  applications  are 
restoring  life  and  energy  to  parts  which,  before  they  were  appli- 
ed, seemed  entirely  dead!  It  is  under  this  impression,  that  sti- 
mulants are  continued  of  a  strength  which  parts  thus  inflamed 
cannot  bear;  the  disease  is  aggravated  by  them,  and  the  cries 
from  all  sides  are  such  as  would  melt  the  most  rugged  nature. 

In  the  third  stage,  this  gangrene  ceases,  the  sloughs  fall  off, 
the  muscles  become  exposed,  the  part  assumes  once  more  the 
appearance  of  a  common  sore,  but  fearfully  enlarged  ;  a  high 
and  glossy  red,  and  .a  smooth,  shining,  uninterrupted  surface, 
mark  the  continuance  of  the  inflammation  and  disease  ;  but  it 
the  sores  are  to  do  well,  it  is  known  by  a  rough,  granulating- 
surface,  somewhat  dry,  and  of  a  paler  colour. 

If  the  patient  is  to  die,  the  gangrene  or  wasting  of  the  cellular 
sheaths  proceeds  ;  the  skin  first  sloughs  off;  then  the  fascia  is 
destroyed;  those  divisions  a«d  lamella  of  the  fascia,  which  dive 
betwixt  the  muscles  to  enclose,  protect,  and  nourish  them,  are 
next  affected  ;  the  matter  continues  slimy  and  thick,  and  in  pro- 
digious quantities  ;  the  muscles  are  divided  irom  each  other 
more  and  more.  In  many  who  suffered  under  the  disease  at 
the  same  time  with  Joiner  (the  boy  above  mentioned),  you 
could  have  laid  your  hand  edgeways  betwixt  the  several  mus- 


Of  the  Hospital  Sore  or  Gangrene.  2: 

desofthe  thigh.  Then  the  vomiting,  diarrhoea,  and  nervous 
symptoms  increase,  the  pain  '.s  dreadful ;  the  cries  of  the  suffer- 
ers are  the  same  in  the  night  as  in  the  day-time  ;  they  are  ex- 
hausted in  the  course  of  a  week,  and  die:  or  if  thev  survive, 
and  the  ulcers  continue  to  eat  down  and  disjoin  the  muscles, 
the  great  vessels  are  at  last  exposed  and  eroded,  and  the  v  bleed 
to  death*. 

These  are  the  forms  which  this  disease  assumes  when  it  at- 
tacks an  amputated  stump,  a  broad  and  open  wound,  a  laceration 
of  the  skin,  or  any  surlace  which  is  apt  to  income  a  flat  sore. 
But  when  itattacks  a  narrow  wound,  as  a  bullet  wound,  a  wound 
with  any  pointed  instrument,  even  the  prick  of  a  nail  in  the  fin- 
ger, it  assumes  at  once  the  form  of  an  Erysipelatous  Gangrene 
(Erysipelas  Gangrenosa)  ;  and  when  this  disease  prevails  in  the 
hospital,  you  rriay  see  even  a  nurse,  from  some  slight  hurt  in 
the  hand,  which  at  another  time  could  have  done  no  harm,  havr 
one  day  a  swelling  of  the  wound,  on  the  next  an  erysipelas  of 
the  arm,  with  dreadful  pain  and  low  fever  ;  on  the  third  day  the 
arm  will  become  livid,  and  covered  with  vesicles,  and  in  two 
days  more  fall  into  gangrene  ;  the  woman  oppressed  in  the 
meanwhile  with  hiccup,  low  delirium,  and  other  symptoms  of 
approaching  death. 

A  stump  which  has  not  adhered  is  a  flat  wound  peculiarly 
apt  to  be  seized  with  this  dreadful  disorder  ;  and  in  wards 
where  the  disease  prevails,  amputation  should  rot  he  performed. 
It  is  almost  impossible  to  heal  the  stump  ;  it  sloughs,  ulcerates, 
shrinks,  becomes  pyramidal  ,  and  to  the  very  last  moment  ot 
its  healing,  and  even  when  the  scar  seems  formed,  or  is  about 
to  be  formed,  the  patient  is  liable  to  rigors,  slight  vomiting,  a 
quick  and  irritable  pulse  ;  and  then,  in  the  course  of  a  U  w 
days,  the  stump  is  burst  open  by  inflammation,  and  spreads  it- 
self into  a  broader  surface  than  even  when  the  limb  was  cut  off. 
The  danger  of  this  inflammation  and  ulcer  of  the  stump  is  ex- 
treme ;  the  least  evil  that  can  ensue  from  it,  is  a  great  wasting 
of  substance,  an  exfoliation  of  the  bone,  and  a  conical  stump  : 
but  we  are  often  disappointed  even  of  this  imperfect  cure,  viz. 
in  the  form  of  a  conical  stump;  for  it  happens  in  an  ulcerating 
stump,  as  in  other  sores,  that  the  greater  arteries  are  eroded,  and 
then  the  patient  almost  inevitably  dies.  In  one  day  I  saw  three 
stumps  burst  open  in  this  manner,  each  of  which  was  so  nearly 


*  The  author  has  defcribed  this  difeafe  as  it  appeared  among  the  Englifh  failors 
wounded  on  the  nth  Gclober,  1 798,  in  an  engagement  with  the  Dutch,  and  after- 
wards put  into  an  hofpital  at  Yarmouth.  There  were  three  hundred  wounded 
Dutch  failors  in  the  fame  hofpital,  feparated  by  a  wall,  among  whom  there  w-b 
do  appearance  of  the  difeafe.     S. 


28  Of  the  Hospital  Sore  or  Gangrene, 

cicatrized,  that  you  could  have  covered  the  small  spot  that  was 
left  unhraled  with  the  tip  of  the  little  finger. 

This  ulcer  and  gangrene  is  in  an  hospital,  what  puerperal  fe- 
ver is  in  a  lying-in  ward ;  it  is  an  infection  to  which  all  are 
equally  exposed  ;  but  it  is  resisted  by  health  and  strength,  and 
favoured  by  weakness  or  disease.  Excesses,  drunkennesses, 
cold,  and  everv  cause  of  weakness,  expose  the  constitution  to 
its  attack.  If  diarrhoea,  fever,  dysentery,  or  an  old  inter- 
mittent, or  even  a  common  cold,  attack  a  wounded  man  who 
lies  in  an  unhealthy  hospital,  the  first  febrile  symptoms  are  im- 
mediately followed  by  this  terrible  disease.  The  moment  that 
a  man  is  struck  with  it,  you  mjiy  observe  him  become  pale,  sal- 
low, languid,  low-spirited,  with  a  heavy  eye,  a  confused  head,  a 
loathing  of  food,  a  fretful  pulse,  and  in  short,  a  universal  disor- 
der, which  he  can  neither  account  for  nor  describe*;  and  whether 
this  disease  appear  first  in  the  system,  or  in  the  part  wounded, 
its  progress  is  the  same.  When  I  have  observed  in  any  case 
the  sore  to  be  first  affected,  I  have  noted  it  as  a  sure  symptom  of 
the  approaching  disorder  of  the  whole  system  ;  or  when  the 
system  was  first  affected,  I  have  marked  that  as  a  sure  presage 
of  the  sad  change  that  was  soon  to  appear  in  the  sore.  What, 
then,  is  the  surgeon  to  do?  Is  he  to  try  experiments  with  oint- 
ments and  plasters,  while  men  are  dying  around  him  ?  Is  he  to 
seek  for  washes  or  dressings  to  cure  such  a  disease  as  this  ?  Is 
he  to  expend  butts  of  wine,  contending,  as  it  were,  against  the 
elements  ?  No  !  Let  him  bear  this  always  in  mind,  that  no 
dressings  have  ever  been  found  to  stop  this  ulcer  ;  that  no  quan- 
tities of  vvine  or  bark  which  a  man  can  bear,  have  ever  retard- 
ed this  gangrene  ;  let  him  bear  in  mind,  that  this  is  a  hospital 
disease  ;  that  without  the  circle  of  the  infected  walls  the  men 
are  safe  ;  let  him,  therefore,  hurry  them  out  of  this  house  of 
death  ;  let  him  change  the  wards,  let  him  take  possession  of 
some  empty  house,  and  so  carry  his  patients  into  good  air;  let 
him  lay  them  in  a  school-room,  a  church,  on  a  dunghill,  or  in  a 
stable. 

Till  some  change  of  situation  be  accomplished,  little  can  be 
done  for  men  labouring  under  this  plague  ;  but  when  the  dis- 
ease first  breaks  out  and  rages,  and  while  you  are  meditating 
some  change,  or  concerting  plans  for  suppressing  the  disease, 
you  will  find  opium  of  infinite  service  in  checking  the  diarrhoea 
and  lever,  for  these  are  greatly  aggravated  by  the  irritation  and 
pain ;  you  must  try  to  support  the  strength  of  your  people  by 
wine  and  cordials,  and  generous  food,  administered  sparingly; 
and  be  careful  not  to  overload  their  stomachs  with  bark,  at  a 
time  wh<* n  they  are  little  able  to  bear  any  thing  but  a  decoction, 
or  a  small  dose  of  the  powder.     As  for  external  applications, 


Of  the  Hospital  Sore  or  Gangrene.  29 

tinctures  of  myrrh,  aloes,  and  other  drugs,  still  more  stimulant, 
are  improperly  used  in  this  case,  as  they  have  no  effect  while 
the  slough  remains,  and  when  it  gives  way,  produce  unspeaka- 
ble torture.  Of  these  I  cannot  approve  ;  keep  your  tinctures 
and  balsams  for  fistulas,  and  your  torturing  stimulants  for  those 
local  diseases  which  may  be  cured  by  them  ;  but  this  not  being 
a  local  disease  cannot  be  cured  by  local  applications,  and  there- 
fore the  mildest  are  the  best ;  as,  for  instance,  a  solution  of  sal- 
saturni,  which  is  a  gentle  astringent. 

I  think  that  in  this  hospital  ulcer  I  have  seen  gentle  evacu- 
ants  useful  ;  but  I  am  so  undecided  with  regard  to  the  true  prac- 
tice in  this  disease,  that  I  speak  with  diffidence,  and  would  have 
you,  if  you  do  venture  into  this  difficult  path,  proceed  with  so 
much  caution,  that  you  may,  as  it  were,  feel  your  own  way  ;  if 
you  use  evacuations,  or  a  strict  diet,  it  is  but  for  a  time,  and  in 
the  expectation  of  renewing  your  stimuli  gradually,  and  giving 
them  a  greater  power  over  the  system. 


(     30     ) 


DISCOURSE  III. 


ON  BANDAGES. 


SECTION    I. 


On  the  various  uses  of  Bandages. 

XjANDAGES  arc  useful  not  only  for  the  mere  tying  up  of 
a  wound,  but  by  them  many  important  operations  in  surgery 
are  performed,  more  interesting,  though  less  striking,  than  the 
cures  effected  by  the  knife.  In  wounds,  in  abscess,  in  fistulas, 
in  any  general  disease  of  a  limb,  bandaging  is  the  chief  opera- 
tion of  surgery  ;  what  the  knife  cures,  it  partly  destroys  ;  what 
the  bandage  cures,  it  saves. 

1st.  Although  in  recent  wounds,  it  is  with  plasters  and  su- 
tures that  we  unite  the  parts  point  to  point,  yet  it  is  with  the 
bandage  that  we  support  the  limb,  preserve  the  parts  in  conti- 
nual and  perfect  contact  with  each  other,  and  prevent  any  strain 
upon  the  sutures  with  which  the  parts  are  immediately  joined, 
and  we  often  unite  parts  by  the  bandage  alone.  The  Uniting 
Bandage  has  been  long  known  by  that  name.     But  it  is  particu- 


Of  the  various  uses  of  Bandages.  3 1 

larly  to  be  observed,  that  in  gunshot  wounds,  and  other  bruised 
wounds,  though  it  would  be  imprudent  to  sew  the  parts,  since  it 
is  impossible  that  they  should  altogether  unite,  yet  the  gentle 
and  general  support  which  we  give  by  a  compress  and  bandage, 
prevents  them  from  separating  tar  from  each  other,  unites  the 
deep  parts  early,  and  lessens  the  extent  of  that  surface  which 
must  naturally  fall  into  suppuration. 

2dly.  Although  in  the  haemorrhagy  from  amputation,  or  in 
any  regular  piece  of  surgery,  we  trust  to  ligatures  alone  ;  in 
the  hsemorrhagy  of  wounds,  we  cannot  always  find  the  artery  ; 
we  dare  not  always  cut  the  parts,  for  fear  of  greater  danger  ;  we 
are  often  alarmed  with  bleedings  from  uncertain  vessels,  or 
from  members  of  vessels,  or  from  veins  as  well  as  arteries : 
these  are  hsemorrhagies  to  be  suppressed  by  a  compress,  or 
sponge,  which  is  but  an  instrument  of  compression,  serving  to 
give  the  bandage  its  perfect  effect.  Frequently,  in  bleedings 
near  the  groin,  or  the  arm-pit,  in  the  angle  of  the  jaw,  wherever 
the  bleeding  is  rapid,  the  vessels  uncertain,  the  cavity  deep,  and 
the  blood  not  to  be  commanded  by  a  tourniquet,  and  where  the 
circumstances  forbid  a  deliberate  and  sure  operation,  we  trust 
to  compress  and  bandage  alone. 

If  a  compress  be  neatly  put  upon  the  bleeding  arteries,  if 
there  be  a  bone  to  resist  the  compress,  or  even  if  the  soft  parts 
be  firm  below,  and  the  bandage  be  well  rolled,  the  patient  is  al- 
most secure*.  But  such  a  roller  must  be  rolled  smoothly  from 
the  very  extremity  of  the  fingers  or  toes ;  the  member  must 
be  thoroughly  supported  in  all  its  lower  parts,  that  it  may  bear 
the  pressure  above.  It  is  partial  stricture  only  that  does  harm, 
creates  intolerable  pain  and  anxiety,  or  brings  on  gangn.  ne. 
Ha?morrhagy  requires  a  very  powerful  compression,  which 
must  therefore  be  very  general,  and  must  be  made  very  cunning- 
ly and  skilfully,  to  be  either  supportable  or  safe  ;  it  must  not  be 
made  over  the  bleeding  arteries  only,  which  is  all  that  the  sur- 
geon thinks  of  in  general,  nor  must  it  be  begun  at  that  part 
where  it  is  particularly  required  ;  the  bandaging,  for  example, 
by  which  a  wounded  artery  at  the  bending  of  the  fore-arm  may 
be  cured,  must  be  begun  at  the  very  tips  of  the  fingers  ;  each 
individual  finger  must  be  rolled  ;  the  roller  must  be  continued 
over  the  hand,  with  the  greatest  attention  to  leave  not  a  single 
point  unsupported,  nor  subject  to  strangulation.     It  must  be 

•  Notwithstanding  what  is  here  faid  in  favour  of  comprcflion,  as  a  remedy  L 
the  fuppreffion  of  hemorrhage,  it  ought  never  to  be  trulted  to  where  there  is  reafon 
to  apprehend  an  artery  of  any  considerable  fize  is  wounded;  particularly  wher. 
the  lurgeon  is  obliged  to  leave  his  patient  for  fame  confiderable  time,  or  refides  ar 
a  diftance  from  him.  Tie  the  veffels  and  then  apply  comptellion,  and  every  thing 
ire.    S. 


32  On  the  various  uses  of  Bandages. 

rolled  carefully  and  firmly  upwards  along  the  fore-arm ;  and 
thus  the  whole  of  the  limb  will  be  supported  against  that  pres- 
sure which  is  made,  particularly  upon  the  wounded  part.  When 
thus  rightly  applied,  the  firmer  the  bandage  is,  the  less  apt  it  is 
to  be  attended  with  pain  or  danger*.  Gangrene  is,  you  may 
easily  perceive,  the  effect,  not  of  a  firm  bandage  because  it  is 
firm,  but  because  it  is  partial,  and  strangles  some  single  point  of 
the  limb. 

From  these  considerations,  we  understand  why  surgeons 
failed  in  the  cure  of  aneurisms,  notwithstanding  their  curious 
contrivances  of  plates,  and  screws,  and  springs,  and  cushions ; 
they  were  too  curious,  all  their  care  was  to  make  the  pressure 
upon  some  single  point  of  the  limb ;  and  all  the  fault  of  their 
instruments  was  this  partial  pressure. 

3dly,  In  abscesses,  where  matter  is  working  downwards 
along  the  limb  (seeking  out,  as  it  were,  the  weak  parts),  under- 
mining the  skin  and  wasting  it,  insulating  and  surrounding  the 
muscles,  and  penetrating  to  the  bones,  the  bandage  does  every- 
thing. The  expelling  bandage,  the  propelling  bandage,  the  de- 
fensive bandage,  were  among  the  names  which  the  older  sur- 
geons gave  to  the  roller  when  it  was  applied  for  these  particular 
purposes ;  and  these  are  properties  of  the  roller  which  should 
not  be  forgotten.  It  is  obvious,  that  of  all  bandages  the  sim- 
ple roller  is  the  best  fitted  for  a  diseased  limbf,  "but  the  moment 
you  begin  to  apply  this  simple  bandage,  you  will  meet  with  un- 
expected difficulties  ;  you  will  feci  the  necessity  of  use  and  prac- 
tice towards  rolling  a  limb  with  neatness  and  perfect  effect ;  you 
will  find  yourselves  awkward  at  first,  and  would  almost  believe, 
that  a  simple  roller  could  never  be  made  a  perfect  support  to  a 
diseased  joint;  you  will  perceive  your  bandages  to  be  irregular 
from  the  first,  and  they  will  be  slackened  in  a  few  hours.  Prac- 
tice will  convince  you,  that  the  firmness  and  neatness  of  a  ban- 
dage depend  altogether  upon  these  two  points,  first,  upon  the 
turns  succeeding  each  other  in  a  regular  proportion  ;  and,  se- 
condly, upon  making  reverses,  wherever  you  find  any  slack- 
ness likely  to  arise,  from  the  varying  form  of  the  limb.  Thus, 
in  rolling  from  che  foot  to  the  ancle,  leg  and  knee,  you  must 
take  care  first,  that  the  turns,  or,  as  the  French  call  them,  Dol- 


*  I  cannot  agree  with  the  author  in  this  reafoning :  if  you  apply  a  bandage 
with  fuffkient  firmnefs  at  the  upper  part  of  the  limb  to  flop  the  circulation,  I  do 
not  fee  how  preffure  upon  the  lower  part  will  prevent  gangrene  ;  and  unlefs  the 
circulation  is  prevented,  mortification  will  not  enfue.     S. 

f  This  rule  is  not  admifftblc  in  the  unlimited  degree  in  which  it  is  here  laid 
down  ;  on  many  occafions  the  many  tailed  bandage  is  preferable,  as  in  a  fuppura- 
ting  compound  fracture,  and  in  all  cafes  where  moving  the  limb  frequently  would 
be  injurious.     S. 


On  the  various  uses  of  Bandages. 


33 


loires,  of  the  roller-  lie  over  one  another  by  just  one  third  of 
the  breadth  of  the  bandage  ;  and  secondly,  that  at  every  difficult 
part,  as  over  a  joint,  you  turn  the  roller  in  your  hand,  make  an 
angle,  and  lay  the  roller  upon  the  limb  with  the  opposite  flat  side 
towards  it ;  you  must  turn  the  bandage  so  as  to  reverse  it, 
making  what  the  French  call  a  Ren  verse  e  of  the  roller,  at  the 
ancle,  at  the  calf  of  the  leg,  at  the  kneef ;  wherever,  upon 
making  a  turn  of  the  roller,  you  perceive  that  it  will  fall  slack, 
you  make  a  reverse  of  the  bandage,  and  at  each  reverse  you 
put  in  a  pin  to  prevent  it  falling  down  ;  you  must  be  careful  to 
roll  your  bandage  from  below  upwards,  and  support  the  whole 
limb  by  a  general  pressure,  that  you  may  be  able  to  support  the 
diseased  part  with  a  particular  pressure  ;  you  must  lay  com- 
presses upon  the  hollows,  and  upon  the  bed  of  each  particular 
abscess,  and  change  the  place  of  these  compresses  from  time  to 
time,  so  as  now  to  prevent  matter  sinking  into  a  particular  hol- 
low, now  to  press  it  out  from  a  place  where  it  is  already  lodged, 
and  again  to  re-unite  the  surface  of  an  abscess  already  com- 
pletely formed,  from  which  the  matter  has  been  already  dis- 
charged. 


- 


4ihly,  In  the  case  op  a  fistula,  or  where  the  abscess  has 
hardened  into  a  callous  tube,  while  you  pare  away  the  callous 
edges,  or  cauterize  them ;  while  vou  open  particular  mouths  of 
the  fistula  with  the  knife,  or  dilate  them  with  sponges  (which 
you  should  prefer  if  you  are  afraid  of  an  hospital  sore)  ;  while 


*  The  Dolloires  arc  marked  in  the  plate,  i.  2,  3. 

f  Renverfecs  of  the  roller  are  marked  in  the  fame  plate,  a,  b,  c. 

E 


34  On  the  various  uses  of  Bandages. 

you  stimulate  the  internal  surfaces  with  gentle  solutions  of  cor- 
rosive sublimate,  spirits,  or  stimulant  balsams,  as  solutions  of 
gum,  aloes,  &c.  in  spirits  ;  you  must  lay  such  a  train  of  com- 
presses along  the  course  of  the  fistula  as  will  bring  the  sides  in- 
to contact ;  and  when  you  use  a  seton,  whether  it  be  in  fistula, 
to  excite  the  tube,  or  in  irregular  abscess,  to  lead  the  matter,  and 
concentrate  the  disease,  you  learn  by  means  of  the  seton  the  di- 
rection of  every  irregular  passage,  and  hollow  tract  in  the  limb, 
and  know,  of  course,  where  to  lay  your  train  of  compresses, 
and  what  form  to  give  them. 

It  is  in  the  complicated  case  of  a  swelled  and  diseased  limb 
that  we  are  sensible  of  all  the  uses  of  a  bandage,  which  is  a  uni- 
versal cure  for  all  its  disorders.  By  the  bandage  we  dissipate 
the  leucophlegmatic  swelling,  abate  the  inflammation,  prevent 
the  extension  of  matter,  lessen  suppurating  cavities,  close  the 
walls  of  fistulas,  procure  the  re-union  of  surfaces  which  have 
suppurated.  The  patient  is  sensible  of  an  easy  and  pleasant 
firmness  from  the  bandage,  and  the  limb  is  actually  supported 
against  accidents,  and  the  further  extension  of  the  disease.  This 
effect  of  bandage  is  observable,  not  merely  in  this  single  case 
of  an  ill  bandaged  limb,  but  is  equally  obvious  and  interesting 
in  other  cases ;  for  in  varices,  though  a  permanent  bandage  is 
usually  required,  yet  sometimes  the  parts  are  so  strengthened 
by  a  roller  that  they  recover  their  tone.  It  is  also  by  curing 
this  low  inflammation,  restoring  the  tone  of  the  parts,  and 
strengthening  their  action,  that  bandage  cures  ulcer  in  the  leg. 
If  you  have  seldom  seen  an  ulcer  even  rendered  stationary  by  a 
bandage,  much  less  cured  by  it,  remember  how  very  ignorantly 
you  have  seen  such  rollers  applied.  You  have  seen  them 
drawn  round  the  ulcer,  round  the  shin  alone,  with  the  firmness 
of  a  tourniquet ;  the  middle  of  the  leg  bound  very  tight,  the 
foot  swelled,  the  ulcer  inflamed,  the  marks  of  the  roller  left  in 
large  ridges  ;  you  have  seen  it  recovering  in  the  morning,  only  to 
be  tortured  into  the  same  condition  before  night!  Instead  of  this 
it  should  be  rolled  from  the  very  extremities  of  the  toes,  and  then 
roll  it  as  tight  as  you  will  you  can  do  no  harm.  It  should  be  rolled 
in  the  morning  upon  rising  from  bed,  in  such  a  manner  as  to  fit 
it  to  bear  the  fatigues  of  the  day  ;  to  support  and  defend  the 
ulcer,  and  keep  the  swelling  all  above  the  sore  ;  this  constitutes 
the  true  value  of  the  sticking  plasters,  which  have  been  so  suc- 
cessfully used  by  Dr.  Bainton  :  First,  The  sore  is  thoroughly 
cleansed,  its  edges  smoothed  and  wrought  forwards,  and  firmly 
compressed  by  the  drawing  of  the  plaster :  Secondly,  The  limb 
is  rolled  from  the  toes  to  the  sore,  then  over  the  sore,  and  some 
way  upwards,  so  as  to  secure  the  relaxed  parts  ;  the  bandage  so 
rolled,  by  a  skiliul  hand,  is  the  only  certain-cure  ;  neither  oint- 


On  the  various  uses  of  Bandages.  35 

ments  nor  mercurial  preparations,  nor  sponges,  nor  leaden 
platts,  will  cure  an  ulcer  :  it  is  to  be  cured  onh  bv  firm,  equa- 
ble, and  perfect  compression,  which  must  be  renewed  more  than 
once  a  day  it  the  bandage  becomes  loose.  There  is  no  inflam- 
mation of  the  lower  extremities  in  which  I  do  not  experience 
the  good  effects  of  firm  rolling.  Even  mere  feeling  and  vul- 
gar experience  instruct  a  man  when  he  has  an  ancle  sprained  to 
bind  it  firm  ;  and  in  a  diseased  bursa  (as  in  a  relaxation  ot  the 
knee-joint),  that  disease,  which  with  but  a  little  indulgence,  a 
very  little  encouragement  of  fomentations,  poultices,  bleedings, 
and  low  diet,  would  end  in  white  swelling  ol  the  knee  ;  may 
be  stopped  even  by  so  simple  a  matter  as  a  well  rolled  bandage. 
Stimulants,  as  calomel,  opium,  and  good  diet,  will  keep  the  s\  s- 
tem  well ;  and  the  joint  itself  may  be  excited  to  a  healthy  ac- 
tion, by  pouring  hot  mineral  waters  on  it,  by  animal  oils,  cam- 
phor, laudanum,  frictions,  and  most  of  all  by  supporting  the 
action  thus  excited  by  a  general  roller,  wtll  and  carefully  appli- 
ed, and  by  particular  compresses  applied  upon  each  bursa.  By 
a  compress,  merely  on  each  side  ot  the  knee-joint,  when  the 
great  Capsule  of  the  joint  itself  was  swelled,  I  have  reduced 
the  size  of  a  dropsical  knee  by  the  quantity  of  three  or  four 
ounces  in  a  night's  time  ;  the  fluid  being  fairly  and  unequivo- 
cally absorbed,  without  any  deception  arising  from  its  being 
pushed  into  the  surrounding  cellular  substance.  I  have  fre- 
quently in  a  few  days  reduced  prodigious  dropsical  swellings  of 
the  knee,  relieved  the  patient  from  great  pain,  restored  the  use 
of  the  limb,  and  made  an  absolute  and  permanent  cure.  The 
common  sprain  of  the  ancle  also  is  a  slighter  disease,  a  tempo- 
rary one  of  those  bursas  which  accompanv  the  Peromei  tendons. 
It  seems  to  be  accompanied  with  very  quick  and  active  inflam- 
mation ;  if  it  be  but  a  little  indulged  by  long  fomentation  in 
tepid  water,  leeches,  poultice,  and  such  things  as  relax  the 
parts,  it  is  rendered  a  very  tedious  disease,  and  the  joint  be- 
comes swelled  and  gummy,  lame  for  months,  and  rheumatic 
tor  years,  and  liable  to  be  easily  hurt  again  by  the  slightest  strain 
upon  it ;  but  if  this  swelling  be.opposed  vigorously  by  hot  fo- 
mentation, continued  but  for  a  short  time,  camphorated  spirits, 
a  very  firm  bandage,  and  long  compresses  firmly  pressed  down 
behind  the  ancle,  and  if  after  a  few  days  cold  water  be  poured 
upon  the  joint,  if  it  be  rubbed,  and  still  firmly  bandaged  alter  it 
seems  well,  it  will  be  easily  cured,  and  no  remaining  weakness 
left  to  remind  us  of  the  accident. 

I  have  reduced  all  bandages  to  those  few  which  are  repre- 
sented at  the  head  of  this  chapter.      They  are  as  follow. 

The  Linteum  Scissum,  or  Split  Cloth,  marked  No.  1.  is 
peculiarly  adapted  to  the  head  :  it  covers  the  whole  scalp,  and 


36  On  the  various  uses  of  Bandages. 

its  legs  or  split  parts  tie  firmly  round  the  occiput  and  forehead ; 
it  may  be  made  with  six  or  with  eight  tails,  according  to  the 
parts  you  wish  to  compress*. 

The  Single  Split  Cloth,  or  bandage  with  four  tails,  No. 
2.  which  is  called  the  Capistrum  or  Stirrup,  or  the  Fun  da  or 
Sling,  is  the  proper  and  peculiar  bandage  for  the  lace  :  in  cuts 
of  the  forehead,  or  of  the  face,  of  the  nose,  of  the  lips,  in  frac- 
tures of  the  jaws,  and  in  every  wound  which  is  beyond  the  cir- 
cle of  the  hairy  scalp,  we  use  the  Sling,  or  Double-tailed  Ban- 
dage. 

The  T  Bandage,  No  3.  which  is  named  from  its  resem- 
bling the  letter  T,  is  the  peculiar  bandage  of  the  bod)'.  If  the 
brtast  or  belly  be  wounded,  we  make  the  circular  (a)  very 
broad,  which  serves  as  the  proper  bandage  of  the  bodv,  and  we 
split  the  tail-part,  (b)  and  passing  one  leg  over  each  side  of  the 
neck,  we  pin  it  to  the  circular,  so  that  it  forms  a  suspensary  for 
the  main  bandage,  which  prevents  its  slipping  down.  But  if 
we  have  a  wound,  or  disease,  or  operation  neat  the  groin  or  pri- 
vate parts,  the  tail-part  becomes  then  the  most  important  part 
of  the  bandage  ;  then  the  circular  is  smaller,  and  goes  round 
the  pelvis,  while  the  tail-part  is  made  very  broad.  When  the 
disease  is  in  the  private  parts,  perineum  or  anus,  we  often  split 
the  tail  according  to  circumstances  ;  but  when  the  disease  is  in 
one  groin,  we  generally  leave  the  tail-part  of  the  bandage  entire 
and  broad. 

The  Roller,  No  4.  is  the  peculiar  bandage  of  the  limbs, 
for  accomplishing  all  those  objects  which  I  have  just  explained 
to  you  ;  it  serves  for  the  limbs,  shoulders,  haunches,  and  occa- 
sionally for  the  body  ;  it  is  often  singularly  useful  in  bandaging 
the  head,  where  peculiar  firmness  is  required,  and  there  always 
you  are  to  use  the  double-headed  rollcrj'.  You  take  one  head 
of  the  roller  in  each  hand,  and  by  that  which  is  in  your  left  hand, 
you  fix  down  the  turns  of  that  which  is  in  the  right,  so  that  you 
can  make  your  bandage  smoothlv  firm  over  the  whole  head,  can 
knot  it  at  particular  points,  can  turn  it  in  every  direction,  and 
fit  it  to  every  occasion.  Wherever  the  roller  is  to  be  used  as  a 
uniting  bandage  (i.  e.)  to  be  applied  round  any  part,  so  that  the 
legs  meet  and  cross  each  other  over  a  wound  (to  draw  its  lips 
close  together),  we  make  a  slit  in  the  roller,  see  No.  5.  and  pass 
one  of  the  rolls  through  it,  and  thus  we  make  the  decussation 
of  the  bandage  very  sure,  and  give  it  peculiar  effect  upon  the 


*  Marginal  plate  at  the  beginning  of  this  chapter. 

f  In  all  injuries  of  the  head,  which  render  bandaging  neceflary,  a  double-headed 
roller  is  by  far  the  bell :  generally  a  common  night-cap  v.:!l  confine  the  dreiling=, 
tvA  anfwer  the  purpofes  of  a  bandage.    S. 


Of  the  four-tailed  Bandage  or  single  split  cloth.  37 

wound.  These  are  the  four  bandages  which  I  proceed  to  de- 
scribe, and  I  believe  I  shall  satisfy  you  that  you  mav  throw 
aside  every  other. 


SECTION    11. 


Of  the  four- tailed  Bandage  or  Shigle  Split  Cloth 


Fig.  7. 


i 


Ffq.9, 


Mtyj.0* 


The  Four-Tailed  Bandage,  or  Single  Split  Cloth,  is  the  pe- 
culiar bandage  for  the  forehead,  face,  and  jaws  ;  if  the  forehead 
be  the  part  wounded,  this  simple  and  very  convenient  bandage 
is  applied  as  in  fig.  7.  The  bandage  is  made  by  taking  a  strip 
of  cloth  not  quite  so  broad  as  the  palm  of  the  hand ;  it  is  to  be 
tern  or  split  up  at  each  end,  so  as  to  leave  onlv  a  convenient 
length  of  the  bandage  entire  to  be  applied  to  the  wound  ;  the 
middle  or  unsplit  part  (a)  is  applied  to  the  forehead,  one  tail 
(b)  is  carried  round  the  back  head  to  meet  its  fellow.  The 
other  tail  (c)  is  carried,  as  seems  best,  either  upwards  over  the 
crown  of  the  head,  or  downwards  so  as  to  tie  under  the  chin. 


38  Of  the  four-tailed  Bandage  or  single  split  cloth. 

If  the  top  of  the  head  or  sinciput  be  the  part  wounded,  the 
bandage  may  be  applied,  as  in  fig.  8,  laying  the  unslit  part  (a) 
upon  the  wound,  making  one  tail  (b)  pass  down  under  the  chin, 
while  the  other  (c)  is  long  enough  to  go  round  the  head  like  a 
fillet,  so  as  to  secure  the  bandage  from  slipping  backwards  and 
forwards.  It  may  go  round  to  the  occiput  only,  or  it  may  go 
round  the  occiput  and  return  to  the  forthtad,  and  tie  there. 

In  cufip  of  the  lip  or  nose,  or  both,  after  putting  proper  stitch- 
es in  the  nostril,  lip,  &c.  we  apply  the  funda  or  sling,  its  in  fig. 
9. ;  we  make  one  small  opening  to  receive  the  tip  of  the  nose, 
and  we  do  not  forget  to  make  two  small  holes  opposite  the  two 
nostrils  for  breathing.     It  the  nostril  or  the  tip  of  the  nose  be  much  % 
wounded,  or  almost  cut  off,  after  putting  in  one  or  two  stitches 
with  the  needle,  we  wrap  lint  neatly  round  the  quills  to  put  into 
the  nostrils.     The   quills  serve  for  breathing  through,  and  the 
lint  dilates  and  pads  up  the  nostrils,  so  as  to  keep  the  nose  in  its 
proper  shape,  and  by  distending  the  nostril  it  keeps  the  parts  in 
very  nice  and  equal  contact  ;  one  tail  of  this  bandage  ties  at  the 
nape  of  the  neck,  the  other  crosses  its  fellow  at  the  back  of  the 
head,  and  then  turns  round  to  meet  it,  and  to  tie  on  the  fore- 
head ;  and  sometimes  the  lower  part  also  is  brought  round  to 
tie  at  the  forehead.     If  the  upper  lip  be  cut,  and  a  bandage 
needed  (which  seldom  is  the  case),  it  is  almost  superfluous  to 
say  that  this  bandage  will  serve  the  purpose.     It  serves  also  in 
cuts  of  the  lower  lip,  though  there  also  we  trust  rather  to  hare- 
lip pins  than  the  bandage  ;  but  this  bandage  is  particularly  use- 
ful in  supporting  the  lower  jaw  where  it  is  broken.     This  ban- 
dage, when  applied  thus  to  support  the  lower  jaw,  is  named  Ca- 
pistrum  or  Bridle  (as  it  goes  round  the  jaws  somewhat  like  a 
horse's  halter).     In  some  cases  the  circumstances  require  us  to 
support  the  chin  particularly,  and  then  the  unslit  part  of  the  ban- 
dage is  applied  upon  the  chin,  with  a  small  hole  to  receive  the 
point;  but  where  the  jaw  is  broken,  we  pad  up  the  jaw-bone 
into  its  right  shape,  with  compresses  pressed  in  under  the  jaw, 
and  secured  by  this  bandage  ;  where  we  are  in  fear  of  haemorr- 
hagy  after  any  wound  or  operation  near  the  angle  of  the  jaw, 
we  can  give  the  sling  a  very  remarkable  degree  of  firmness. 
For  this  purpose,  we  tear  the  band  into  three  tails  on  each  side, 
we  stitch  the  bandage  at  the  bottom  of  each  split,  lest  it  should 
give  way  when  firmly  drawn,  and  having  laid  our  sponges  fust 
into  the  bleeding  parts,  and  then  laid  compresses  above  them, 
we  make  the  taiis  of  the  bandage  depart  from  each  other,  just 
over  the  point  where  the  danger  is,  as  in  fig.  10.  where  two  taiis 

(a)  turn  round  under  the  occiput,  and  are  tied  there  ;  two  others 

(b)  cross  each  otht-r  a  little  higher,  come  round  by  the  temples, 
and  tie  upon  the  forehead  ;  and  the  two  other  tails  (c  c)  may 


Of  applying  the  Roller  to  the  Head  and  Jaws.  39 

either  tie  upon  the  top  of  the  head,  or  return  and  tie  under  the 
chin.  In  those  cases,  strong  and  firm  pressure  being  required, 
it  is  not  amiss  to  have  two  legs  of  the  bandage  long  enough  to 
be  just  twisted  at  the  top  of  the  head,  and  to  return  and  tie  un- 
der the  angle  of  the  jaw  with  a  firm  knot.  But  for  purposes 
like  these,  viz.  of  suppressing  haemorrhagy  after  operations,  or 
supporting  a  broken  jaw,  or  plugging  up  a  gunshot  wound 
where  there  is  great  haemorrhagy,  such  as  we  cannot  command 
with  the  needle,  there  is  a  certain  form  of  the  double-headed 
roller,  which  I  shall  presently  recommend  in  preference  to  this ; 
it  is  named  the  Knotted  Bandage. 


SECTION    III. 


Of  applying  the  Roller  to  the  Head  and  Jaws, 


Fig.lh 


Fig.  12. 


Fig.  13 , 


But  the  Roller  is  the  universal  bandage ;  it  supplies  occa- 
sionally the  place  of  all  those  which  are  peculiar  to  the  head  or 
face  ;  is  applied  to  the  head  in  the  following  manner ;  1st,  As 
a  uniting  bandage.  When  the  cut  is,  for  example,  on  the  fore- 
head, the  two  heads  of  the  roller  are  crossed  over  the  cut,  by 
passing  the  head  at  one  end,  through  a  noose  in  the  other  end  ; 
and  I  find  it  of  infinite  advantage  to  touch  either  the  roller  it- 
self, or  the  skin  near  the  cut,  with  some  adhesive  plaster,  which 
gives  the  roller  a  firm  hold  upon  the  skin,  fig.  11.  where  the 
roller  is  supposed  to  cross  over  a  wound. 

2dly,  In  great  lacerations,  or  in  extensive  suppurations  of  the 


40 


Of  Bandage  for  the  Body. 


scalp,  the  general  pressure  which  such  a  case  requires,  may  be 
made  b)  turning  the  double -headed  roller  with  both  hands 
round  the  head;  and  while  the  right  hand  surrounds  the  head 
with  circular  turns,  the  left  hand  crosses  the  top  of  the  head  at 
each  turn  of  the  roller,  and,  when  finished,  it  makes  the  ban- 
dage which  is  drawn,  fig.  12.  It  is  called  the  Capellink 
Bandage,  and  is  the  same  with  that  which  was  a  few  years  ago 
used  for  binding  up  a  stump  after  amputation. 

3dly,  When  the  jaw  is  broken,  the  double-headed  roller 
keeps  the  parts  very  firm,  and  this  bandage  winds  in  every  di- 
rection which  the  exigencies  of  the  case  may  require ;  for  when- 
ever you  wish  to  turn  the  bandage  to  make  it  peculiarly  firm,^ 
you  have  but  to  cross  the  rollers,  and  change  hands.  But  there 
is  nothing  so  peculiar  in  this  form  of  bandage,  nor  so  far  differ- 
ing from  the  capistrum,  or  split  cloth,  as  to  need  a  drawing. 

4thly,  In  every  case  of  dangerous  bleeding  from  about  the 
jaws,  the  parotid  gland,  the  ear,  &c.  I  prefer  that  form  of  the 
double-headed  roller  which  is  seen  in  fig.  13.  when  at  each  turn 


Of  Bandage  for  the  Body.  41 

you  twist  and  knot  the  bandages  over  the  point  where  the  dan- 
ger is;  whence  this  form  of  the  roller  is  tailed  particularly  the 
Knotted  or  Twisted  Bandage. 


section   IV. 
Of  Bimdage  for  the  Body. 

The  best  form  of  bandage  for  the  body  is  the  very  old  one, 
represented  in  fig.  14,  named  Spica,  because,  when  made,  it  re- 
sembles somewhat  an  ear  of  corn.  We  begin  the  bandage  at 
(a),  by  la\  ing  ihe  middle  of  a  double-headed  roller  in  the  axilla  ; 
we  carr\  the  two  heads  first  round  the  body,  then  oblquely  up 
over  the  breast  and  back,  and  make  them  (ross  each  other  over 
the  shoulder,  (b) ;  both  heads  are  then  carried  round  the  affect- 
ed arm  at(c  c),  then  up  again  over  the  same  shoulder,  and  cross 
upon  the  top  of  the  shoulder,  and  thtn  down  again  over  the 
breast  and  back,  so  as  to  make  a  second  turn  (d)  under  the 
sound  axilla,  and  then  the  roller  is  returned  over  the  breast  and 
back  a  second  time  to  the  affected  shoulder.  This  spica  ban- 
dage is  sufficiently  explained  by  the  drawing  ;  it  is  often  made 
over  both  shoulders,  and  is  then  called  the  Double  Spica,  being 
made  with  equal  crossings  on  the  breast  and  back,  and  equal 
crossings  upon  each  shoulder,  both  over  and  under  it.  This 
bandage  is  also  used  in  approaching  the  trunk  of  the  body  from 
the  thigh  :  the  bandage  is  then  called  Spica  Inguinalis,  the  Spi- 
ca of  the  Groin,  and  begins  with  a  turn  round  the  pelvis. 

This  spica,  in  various  forms,  sometimes  turning  more  parti- 
cularlv  round  the  pelvis,  and  sometimes  turning  chiefly  round 
the  limb,  according  as  the  trunk  or  the  limb  is  most  wounded, 
makes  a  verv  firm  bandage.  In  fractures  of  the  clavicle.*  in 
wounds  about  the  upper  part  of  the  breast,  in  hiemorrhagies 
from  the  mammary  arteries  at  the  top  of  the  breast,  in  frac- 
tures near  the  head  of  the  shoulder-bone,  in  amputations  very 
close  to  the  trunk  of  the  body,  we  find  this  bandage,  the  Spica 
Humeri,  very  useful.  The  spica  inguinis  is  equally  useful  in 
hernias  of  the  groin,  in  luxations  of  the  thigh  bone,  in  wounds 
of  the  upper  part  of  the   thigh,  or  lower  part  of  the  belly,  in 

•  In  applying  this  bandage-  for  a  fractured  clavicle,  it  is  neccflary  to  raife  that 
part  of  it  attached  to  the  fcapula,  until  it  is  put  into  complete  coaptation  with  the 
Iternal  portion.  This  is  to  be  effected  by  elevating  the  humerus,  and  a  few  turns 
of  the  roller,  including  the  body  and  arm,  will  retain  i'  in  its  proper  pofition. 
For  a  more  effectual  but  complicated  apparatus  for  fractured  clavicles,  vide  Def- 
fault's  (Euvrcs  Chirurgicales,  vol.  i  p.  9  }.  In  Boyer's  Lectures,  on  the  Difeafes  of 
Bones,  p.  72,  Phil.  edit,  there  is  a  more  fimple  plan  recommended.  The  fpira 
bandage  will  anrwer  all  p  jrpof  -  if  properly  applied.     S. 

'  F 


42 


Of  Bandage  for  the  Body. 


supporting  aneurisms  of  the  femoral  artery,  and  in  a  thousand 
indescribable  cases. 

3dly,  When  the  thorax  is  wounded  or  diseased  ;  when  the 
ribs  are  much  broken  ;  when  the  sternum  is  carious,  with  sup- 
puration ;  when  a  schirrous  breast  has  been  extirpated  ;  when 
we  perform  the  operation  for  empyema,  (that  is,  when  we  make 
an  opening  to  let  out  matter  confined  within  the  chest);  we  use 
the  Napkm*  and  Scapulary,  fig.  15.  It  is  called  Napkin  and 
Scapulary,  because  in  general  it  is  made  by  taking  a  table  nap- 
kin, folded  lengthways  four  or  five  times  ;  which  being  put 
smoothly  round  the  body,  and  pinned  firmly,  is  suspended  by 
the  scapulary,  so  named  from  its  lying  flat  over  the  shoulders. 
The  scapulary  part  of  the  bandage  is  just  a  slip  of  linen  split 
half  its  length,  so  that  its  two  legs  being  laid  round  the  neck, 
the  unsplit  part  before  is  pinned  to  the  circular  or  napkin  ;  and 
the  two  legs  being  made  to  cross  each  other  behind,  are  also 
pinned  to  the  circular,  one  on  one  side,  the  other  on  the  other  side. 

The  T  bandage,  belonging  to  the  groin  or  private  parts,  is  so 
continually  used,  while  almost  all  other  bandages  are  neglected, 
that  it  would  be  as  superfluous  to  explain  it,  as  it  is  useful  to 
explain  the  others. 

*  A  broad  roller  paffed  feveral  times  firmly  around  the  body,  would,  I  think; 
anfwer  better  than  the  napkin.    S. 


(     43     ) 

DISCOURSE  IV. 


ON  HiEMORRHAGY. 


Preliminary  Observations. 

X  O  expire  by  successive  hafmorrhagies  is  perhaps  the  least 
painful  of  deaths,  and  yet  it  is  the  most  awful.  The  repeated 
loss  of  Wood  so  directly  intimates  approaching  dissolution,  and 
the  patient  feels  his  spirit  and  strength  ebbing  so  perceptibly  at 
each  return  of  hajmorrhagy,  that  he  clings  to  life.  Those  of 
the  most  resolute  mind  are  overcome  with  anxiety  which  they 
cannot  conceal,  and  look  round  for  some  one  to  delay  at  least 
the  fatal  moment :  and  the  surgeon  feels  himself  so  responsible, 
that  with  him  it  is  truly  an  anxious  scene.  If  the  bleeding  be 
slow  and  gradual,  from  some  extensive  surface,  as  from  a  poly- 
pus of  the  nostrils,  from  the  womb,  from  the  surface  of  a 
stump,  or  from  some  extensive  sore,  the  surgeon  is  sent  for 
from  hour  to  hour  ;  he  is  called  during  the  night ;  he  is  made 
unhappy  for  weeks  ;  and,  after  repeated  uncontroulable  haemorr- 
hagies,  he  sees  his  patient  expire.  But,  if  there  be  a  sudden 
haemorrhagy  from  the  vessels  cut  in  any  operation,  or  from  an 
aneurism,  or  from  some  great  wound,  the  arteries  of  which  • 
cannot  be  discovered,  there  is  immediate  danger  of  the  patient 
expiring  even  in  the  surgeon's  hands.— ^Let  those  who  have 
witnessed  the  agitation  of  such  scenes  judge  of  the  importance 
of  that  subject  which  I  am  now  to  explain  to  you  ;  indeed  I 
may  appeal  directly  to  yourselves  !  Is  not  this  fear  of  haemorr- 
hagy always  uppermost  in  the  mind  of  the  young  surgeon  ? 
Were  this  one  danger  removed,  he  would  go  forward  in  his  pro- 
fession almost  without  fear. 

Let  us  then  consider  the  following  points  of  doctrine,  with 
the  practical  inferences  that  are  to  be  drawn  from  them :  First, 
The  natural  causes  by  which  an  haemorrhagy  is  stopped  j  se» 


44  Of  the  natural  Causes  of  Hccynorrhagy. 

condly,  The  artificial  means  of  arresting  an  haemorrhage  ;  and, 
thirdly,  The  condition  ot  an  arter)  when  tied  with  a  ligature. 


SECTION    I. 

Of  the  natural  Causes  by  which  an  Hatmorrhagy  is  stopped* 

When  an  artery  has  been  tied  securely,  we  are,  from  that 
moment,  free  Irom  all  uneasintss;  but  when  it  stops  merely 
by  pressure,  by  astringents,  by  the  formation  of  clots,  by  the 
contraction  of  the  artery  itself,  whenever  ha:niorrhag\  stops 
from  any  natural  cause  !  it  is  apt  to  return  ;  and  we  inquire 
anxiously  into  those  natural  causes  for  this  reason.  When 
haemorrhagy  stops  of  its  own  accord,  it  is  neither  irom  the  re- 
traction of  the  artery,  nor  the  constriction  of  its  fibres,  nor  the 
formation  of  clots,  but  by  the  cellular  substance  which  sur- 
rounds the  artery  being  injected  with  blood  ;  and  to  be  assured 
of  this,  we  have  but  to  observe,  what  happens  in  arteries  ot  va- 
rious sizes.  First,  Let  us  suppose  the  wounded  artery  to  be 
so  small  as  just  to  spurt  out  its  blood  ;  the  stream  of  blood 
gradually  lessens,  because  the  artery  is  emptied,  and  the  re- 
sistance to  the  arterial  action  taken  awa\  ;  the  stimulus  being 
gradually  lessened,  the  artery  every  moment  acts  less  power- 
fully :  and  the  blood  being  no  longer  solicited  or  urged  on  by 
the  arterial  contractions,  forsakes  the  open  arter}',  and  moves 
along  the  neighbouring  branches.  The  surgeon  chips  the  point 
of  his  finger  upon  the  mouth  of  the  artery,  and  holds  it  there  ; 
the  outward  bleeding  is  prevented  ;  the  blood  is  extravasatt  d 
into  the  cellular  substance  round  the  mouth  of  the  artery;  the 
cellular  substance  is  slightly  injected  with  blood  ;  that  blood 
coagulates;  and  this  slight  ban ar  is  suffi' ient  to  restrain  the 
bleeding  of  a  small  artery,  till  the  parts  inflame,  and  the  artery 
is  entirely  stopped. 

Secondly,  Supposing  the  artery  still  larger  and  more  power- 
ful, and  that  it  drives  its  blood  ver\  furiously  among  the  cel- 
lular substance,  it  is  not  this  slight  injection  of  the  c  llular  sub- 
stance that  will  rtstrain  the  bleeding!  The  injected  cellular 
substance  will  not  support  the  arterv,  unless  it  is  itseli  also  sup- 
ported. Suppose  then  that  the  surgeon  first  chips  his  thumb 
firmly  upon  the  arterv,  and  then  thrusts  down  a  piece  ol  sponge 
close  to  the  wounded  artery,  applies  over  that  a  compress,  ...id 
bandages  over  all  to  support  the  spoi.ge  :ind  compress  in  ihuir 
place  ;  the  artery  still  bleeds  (though  in  a  restrained  waj )  both 

•  Vide  Appendix  A. 


Of  suppressing  Haemorrhage.  45 

into  the  cellular  substance  beneath  the  sponge,  and  into  the 
sponge  itself,  till  at  last  the  bioocl  coagulating  in  the  sponge, 
and  in  the  cellular  substance,  they  become  as  one  mass,  and 
often  the  sponge  keeps  its  place  till  the  parts  inflame  and  sup- 
purate, when,  of  course,  the  wounded  artery  heals  along  with 
the  other  parts. 

Thirdly,  But  often  it  happens  that  the  blood,  which  was  at 
first  firmly  coagulated,  begins  to  lose  its  consistence  ;  or  that 
b\  some  unwary  motion,  or  by  a  tebrile  excitement,  the  artery 
acts  violently;  more  of  the  cellular  substance  is  filled  with 
blood,  and  the  first  firm  coagulum  and  the  sponge  being  removed 
from  the  mouth  of  the  artery,  the  softer  cellular  substance  be- 
hind them  is  filled  with  fluid  blood,  and  the  artery,  forcing  that 
slighter  obstacle,  bursts  out  again. 


SECTION    II. 

Of  the  artificial  Means  of  suppressing  Haemorrhage. 

Stvptics,  caustics,  and  cauteries,*  aided  by  compression,  were 
the  onlv  means  of  suppressing  haemorrhage,  which  the  older 
surgeons  possessed.  Thesr  have  now  been  almost  entirely  su- 
perseded bv  the  needle  and  ligature,  lor  the  discovery  of  which 
we  are  indebted  to  Ambrose  Paree.f     This  was  a  discovery 

•  Mr.  AfUey  Cooper,  of  London,  mentions  in  his  lectures  a  cafe  in  which  the 
actual  cautery  wis  fucccfsfully  applied  to  the  artery  which  pafTes  through  the  fora- 
men ineilivum,  when  no  other  application  could  (lay  the  hemorrhage.  Mr.  Hey. 
of  l.eed>,  1  have  been  informed,  ufes  the  fame  remedy  in  hxmorrhagies  from  the 
tonfils — S. 

f  rvgaric,  Bovifta,  or  Puff-ball,  was  ftrongly  recommended  fome  years  ago  as  a 
fubuitutc.  lor  the  needle  and  ligature;  but  preffed  fponge,  which  has  been  chief- 
ly ufed  by  the  celebrated  Mr.  White,  is  more  ufelul  than  the  agaric  ;  it  is  like 
it  in  its  operation,  is  really  of  value  in  practice,  not  to  take  the  precedency  of  the 
needle,  but  to  aflift  it.  The  fponge  can  be  very  thoroughly  dried,  it  can  be  com- 
preffed  into  a  very  fmajf  compafs.  it  can  take  any  fhape,  and  may  be  thruft  down 
into  cavities  and  narrow  wounds,  where  the  needle  cannot  go;  it  can  be  made  fo 
hard,  and  pr^flVd  fo  firm,  by  laying  eonipreffes  over  it,  as  to  have  at  once  the 
effect  of  a  campreJs  and  of  a  fponge;  or  rather  of  a  comprefs  having  this  curious 
property,  that  at  firft  it  prefles  moderately,  but  if  one  drop  of  blood  efcapes,  the 
cmn|"J'  fwelk  by  abforbing  that  blood,  ftill  preferves  its  contact  with  the  bleed- 
ing artery,  and  fwells  more,  and  preffes  harder,  exactly  in  proportion  as  fuch 
preffui  e  is  required.  I  his  is  plainly  the  effect  of  a  fponge,  whether  it  be  nitched 
in  betwixt  two  bone-,  to  comprel's  an  artery,  which  the  needle  cannot  reach ;  or 
whether  it  be  laid  flat  upon  an  open  fore,  as  after  cutting  out  the  breaft  ;  or  after 
an  amputation  done  according  to  the  old  fafhion,  where  the  furgeon  ufed  to  dref» 
his  flump  ipen,  and  to  heap  comprcfTcs,  tied  with  a  firm  bandage,  above  each  piece 
of  agjii.  i,r  lponge  'I  he  agaric,  poffelfing  a  degree  of  this  property,  is  of  ufe; 
even  t-ur  common  lint  poffefles  this  quality  of  absorbing  and  swelling  in  a  flight 
degree.  But  the  agaric  and  sponge  are  both  fo  excellent  in  this  refpect,  that  even 
thofe  who  are  the  leaf!  inclined  to  ufe  them,  mult  acknowledge,  that  though  the 


46  Of  suppressing  Haemorrhage. 

which  set  him  higher  in  surgical,  than  Harvey  is  in  medical 
science,  and  it  is  altogether  his  own.  Had  this  invention  been 
well  received,  it  must,  in  the  course  of  two  long  centuries,  have 
improved  surgery  very  greatly,  and  saved  innumerable  lives. 
It  would  have  rendered  many  operations  practicable,  which  the 
old-r  surgeons  never  ventured  upon ;  and  have  made  those 
operations  safe,  which  were  not  so  tdl  of  late  years. 

Paree  neglected  nothing  which  could  give  effect  to  this  im- 
portant discovery.  He  tried  to  demonstrate,  that  even  the  an- 
cients would  have  approved  of  the  practice.  He  also  supported 
his  reasoning  by  facts  ;  by  his  amputations,  and  other  operations, 
and  bv  his  successes  in  the  most  dangerous  wounds.  Nor  can 
we  observe,  without  surprise,  how  perfect  his  operations  were, 
even  in  the  infancy  of  this  discovery. 

Paree  had  three  general  ways  ot  tying  an  artery ;  by  passing  the 
needle  round  the  artery,  clown  on  one  side,  and  up  on  the  other, 
and  so  tying  in  along  with  it  a  quantity  of  flesh ;  or,  by  draw- 
ing the  arteries  out  from  the  wound,  as  from  the  face  of  a  stump, 
by  the  artery  forceps  with  a  spring  handle,  which  he  called  Va» 

agaric  will  often  fail,  it  has  ye*  enabled  furgeons  to  perform  the  greater  amputa- 
tions fafely ;  and  the  fponge,  as  is  proved  by  Mr.  White's  Practice,  is  the  only 
thing  that  can  ftand  by  the  fide  of  the  ligature  to  affift  it.  I  am  fenfible,  that  by 
tbruiting  down  a  fponge  I  have  faved  a  patient's  life,  when  I  could  not  have  ex- 
tricated myfelf  by  any  nicer  operation.  The  fponge  is  often  more  ufeful  than  the 
needle,  and  that,  too,  in  cafes  of  the  greateft  danger.  Wherever  the  wounded 
artery  lies  deep,  and  we  cannot  cut  for  it,  on  account  of  the  nearnefs  of  fome 
great  artery  or  important  nerve,  as,  for  example,  in  the  axilla,  about  the  neck, 
or  about  the  angle  of  the  jaw;  wherever  the  bleeding  artery  is  fo  nitched  in  be- 
tv.'cen  two  bones  that  we  cannot  draw  it  out  with  the  tenaculum,  nor  reach  it  with 
our  crooked  needle,  as,  for  example,  in  the  fore-arm,  or  between  the  bones  of  the 
leg :  in  fhort,  wherever  we  cannot  fee  the  artery,  or  cannot  ftrike  it  fafely  with 
the  needle  ;  wherever  the  bleeding  is  not  fo  much  from  a  particular  artery  as  from 
a  general  furface ;  or  wherever  the  blood  is  thought  to  flow  rather  from  great 
veins  than  from  arteries  (as  in  tearing  out  cancerous  glands  from  the  arm-pit) 
in  all  fuch  cafes  we  ufe  the  fponge,  and  we  ufe  it  in  the  following  manner  :  We 
keep  the  fponge  dry,  and  hard  compreffed,  and  always  ready  for  ufe ;  and  when 
it  is  to  be  ufed,  it  is  cut  into  fmall  pieces,  fquare  or  long,  as  the  incifion  requires, 
and  fmall  threads  are  tied  to  the  fponges,  by  which  they  may  be  drawn  away  in 
due  time.  In  any  dangerous  hsemorrhagy  of  this  kind,  we  choofe  out  a  piece  of 
fponge  proportioned  to  the  fize  of  the  wound,  thruft  it  down  to  the  bottom  of  the 
wound,  fix  it  there  with  the  point  of  the  finger,  either  expref.-ly  upon  the  mouth 
of  the  bleeding  artery,  or,  if  that  cannot  be  diftinctly  feen,  upon  the  place  at  which 
the  artery  blejds ;  then  lay  one  comprefs  above  the  fponge,  a  fecond  comprefs 
above  the  firft,  a  third  above  the  fecond  ;  and  taki.ig  care  to  keep  the  compreffes 
always  fteady  with  one  finger,  to  prevent  the  blood  foaking  into  the  firft  fponge, 
and  diftending  it,  we  pile  one  comprefs  above  the  other,  till  the  whole  riles  fo 
above  the  level  of  the  wound,  that  our  bandage  operates  well  upon  the  whole 
of  this  pile,  which  is  called  Graduated  Comprefs. 

1  advife  you,  on  fuch  occafions,  to  keep  your  tourniquet  fcrewed  during  the 
whole  operation,  that  you  may  not  be  troubled  with  blood  ;  to  flacken  it  flow- 
y,  that  the  dreffings  may  not  be  difcompofed  by  the  too  hidden  return  of  blood  ; 
and  ftill  let  your  tourniquet  remain  loofe  about  the  limb,  and  ready  to  be 
fcrewed,  if  the  artery  fhould  bleed  again. 


Of  suppressing  Hcemorrhage.  47 

let  a  Patin  ;  or  by  striking  the  needle  above  the  place  of  the 
wound,  through  the  flesh  of  the  limb,  down  quite  to  the  bone, 
so  as  to  tie  in  the  great  artery  of  the  limb,  and  along  with  it 
much  of  the  flesh. 

u  If  there  be  a  bleeding  artery,  says  Parous,  in  any  wound, 
dress  the  wound  with  astringents  ;  but  be  careful  at  the  same 
time  to  la\  a  firm  compress  over  the  wound,  and  settle  it  well 
with  a  bandage,  and  then  lay  out  the  wounded  limb  in  an  easy 

Way'  •        r    , 

"  If  this  do  not  serve,  clap  your  finger  upon  the  point  of  the 

artery,  and  wait  patiently  till  a  clot  be  formed. 

u  If  the  arterv  continue  to  bleed,  cut  up  the  wound,  (if  it 
have  been  sewed)  and  pass  a  needle  under  the  artery,  enclos- 
ing along  with  it  in  the  ligature  much  or  little  flesh,  according 
to  the  circumstances  ot  the  case. 

"  If  the  artery  have  shrunk  up  among  the  flesh,  cut  up  the 
wound,  and  tie  the  arterv  higher. 

"  But  should  both  ends  of  the  artery  have  been  still  further 
retracted,  then  continue  your  incision,  and  cut  opeu  the  skin 
freely,  still  pursuing  the  artery;  but  still  careful  ot  the  very  artery 
that  you  are  pursuing,  lest  you  should  cut  it  a  second  time. 

"  In  an  amputated  stump,  draw  your  arteries  out  with  the 
forceps,  tie  them  neatly  with  a  thread  ;  but  if  once  you  miss  the 
artery,  or  your  first  thread  give  way,  do  not  use  the  forceps 
any  more  ;  but  pass  a  needle  four  inches  long  into  the  stump, 
so  as  to  tie  in  the  artery,  along  with  much  of  the  flesh. 

"  These  ligatures  we  are  careful  not  to  withdraw  too  early  ; 
nor  must  they  ever  be  removed  till  the  granulations  of  flesh 
have  grown  up  to  protect  and  strengthen  the  arcery. 

'*  If  these  operations  fail,  we  must  have  recourse  to  caustics, 
vitriols,  or  the  actual  cautery,  which  make  eschars  and  crusts  ; 
and  we  must  be  careful  to  prevent  these  eschars  falling  off  till 
the  flesh  be  formed. 

**  Sometimes  also  the  surgeon  needs  to  cut  the  vessel  entire- 
ly across,  by  which  its  ends,  shrinking  both  ways  among  the 
flesh,  the  flux  stops  :  but  always  the  surest  way  is  to  tie  the 
vessel  before  cutting  it  thus  across." 

This  is  a  system  of  instructions  which  is  fairly  extracted  from 
Parseus's  books,  without  mending  the  text,  and  though  the  sys- 
tem be  now  one  hundred  and  fifty  years  old,  it  is  such  I  believe 
as  the  best  surgeon  at  this  day  in  Europe  could  hardly  improve. 
Incorrectness  of  practice,  surgeons,  from  his  time,  went  back- 
wards for  many  ages  ;  and  it  is  only  alter  much  experience,  and 
by  very  slow  degrees,  that  we  have  learnt  at  last,  that  the  draw- 
ing out  an  artery,  with  the  forceps  or  tenaculum,  and  the  tying 
it  fairly  with  a  smallligature,  the  method  which  appeared  to  the 


48  Of  suppressing  Hemorrhage. 

older  surgeons  to  have  every  fault,  is  absolutely  the  most  se- 
cure*. 

SECTION    III. 

Of  the  condition  of  an  Artery  when  tied  with  Ligatures  :\ 

This,  far  from  being  an  idle  speculation,  is,  I  trust,  an  inqui- 
ry which  will  Kad  to  very  important  conclusions  ;  for  we  natu- 
rallv  inquire,  first,  How  the  artery,  (when  tied  as  in  the  opera- 
tion of  aneurism),  is  affected  by  the  two  ligatures  which  are  put 
round  it?  secondly,  How  the  open  artery  of  a  stump  is  affected 
by  the  single  ligature  with  which  it  is  tied  ?  and  this  leads  di- 
rectly to  a  very  interesting  inquiry,  viz.  How  the  accidental 
bursting  of  arteries  is  to  be  prevented,  and  from  what  causes 
secondary  hsemorrhagies  arise  ? 

An  artery  is  part  of  the  living  system:  it  has  its  vasa  vaso- 
rum,  its  arteries,  veins,  and  lymphatics,  for  the  growth,  support, 
and  nourishment  of  its  own  coats.  Its  circulation  and  nou- 
rishment are  according  to  the  common  laws  of  the  system  ; 
and  having  this  apparatus  of  active  vessels,  it  is  connected  with 
the  surrounding  parts  by  the  common  cellular  substance,  by  les- 
ser arteries  and  veins,  and  the  division  of  that  cellular  sub- 
stance, or  of  the  artery  itself,  is  as  much  a  wound,  as  an  inci- 
sion in  the  skin  is  ! 

Pathology  of  an  Artery  tied  with  Ligatures. 

Retrograde  Blood.  adbefion.  dead.  adbejior:.  Blood  defc ending. 


Ligamentous.  Ligamentous. 


When  ligatures  are  applied  round  an  artery,  they  operate  by 
making  the  several  points  of  the  arterial  canal  pass  through  the 
various  degrees  of  inflammation,  from  adhesion  in  one  point, 
to  gangrene  in  another.     The  space  included  betwixt  the  liga- 

*  By  this  means  we  avoid  including  in  the  ligature  the  large  nerve  which  ufual- 
ly  accompanies  every  large  artery  :  a  circumftance  of  no  fmall  importance.  Vide 
what  is  faid  on  Secondary  Hemorrhage.    S. 

f  Vide  Appendix  B. 


Effects  of  Ligatures  on   Arteries.  49 

tures  falls  into  gangrene,  the  space  immediately  under  the  stric- 
ture of  each  ligature  adheres ;  this  adhesion  prevents  the  gan- 
grene or  the  inflammation  passing  along  the  higher  parts  ot  the 
arterial  canal;  but  the  inflammation  affects  the  aru  rial  tube  a 
little  way  upwards  and  downwards,  so  as  to  thicken  its  walls  and 
contract  its  cavity,  whence  the  canal  of  the  artery  is  obliterated 
a  little  way  beyond  the  exact  place  where  it  is  tied.    • 

The  pathology  of  a  tied  artery  is  thus  reduced  to  common 
principles;  the  obliteration  and  adhesion  ol  a  wounded  artery, 
is  truly  compared  with  the  re-union  of  any  other  wound  ;  and 
one  subject  of  inquiry  alone  remains,  the  most  important  per- 
haps in  surgery,  u  What  are  the  causes  which  prevent  the  ad- 
hesion and  obliteration  ot  an  arter\ ,  and  produce  ulceration  in 
its  coats  ?"  tor  the  causes  which  thus  produce  ulceration  and 
prevent  adhesion  ot  the  artery,  occasion  those  secondary  hae- 
morrhages ol  which  so  many  patients  die !  We  never  leave  our 
patient  bleeding,  yet  it  often  happens,  that  in  the  course  of  a 
few  da\s  alter  an  operation  for  aneurism  or  an  amputation,  the 
blood  bursts  out  suddenly  and  our  patient  bleeds  to  death! 
Direct  hsemorrhagy  trom  a  recent  wound  is  easily  suppressed, 
for  we  see  the  arterv  and  can  tie  it;  but  this  secondary  hae- 
morrhagy  is  peculiarly  dangerous,  it  comes  upon  us  when  we 
are  least  aware  ol  it,  the  parts  are  uheraud,  or  mortified,  and 
the  bleeding  artery  can  be  with  difficulty  found. 


SECTION    IV. 

Of  the  causes  of  secondary  Hcvmorrhagy  ;  and,  first,  of  bursting 
of  tiie  Artet  y  from  the  diseased  state  of  its  coats. 

The  bursting  of  an^HEK-  after  it  seems  securely  tied,  arises 
sometimes  from  the  Unfavourable  state  of  the  artery,  and  from 
its  being  incapable  of  adhesion,  but  much  more  trequtnth  does 
it  happen  from  that  process  which  should  terminate  in  adhesion 
of  the  artery,  proceeding  to  inflammation,  and  ulceration  ol  the 
arterial  coats.  The  diseases  of  the  arterial  system  have  not 
been  sufficiently  investigated.  There  are  few  people  who  have 
passed  their  grand  climacteric  without  having  the  condition  of 
the  whole  arterial  system  very  remarkably  changed.  The  ex- 
treme arteries,  the  active  arteries,  in  all  parts  of  the  system,  are 
less  affected,  they  preserve  their  natural  pliancy;  but  the  great 
arteries  which  serve  but  to  conduct  the  blood,  and  whose  con- 
traction is  less  important  to  the  existence  ot  life,  are  remarkably 
affected.  We  are  sensible  towards  the  decline  of  life,  of  chan- 
ges in  the  great  arterial  trunks,   plainly  unfavourable  to  our 

G 


50  Of  the  Causes  of  Secondary  Hatmorrhagy. 

operations;  the  cellular  substance  which  joins  the  coats  of  the 
arteries  is  diseased;  the  whole  tube  is  but  ill  disposed  to  pass 
through  those  changes  which  are  familiar  to  the  other  sott  parts. 
They  do  not  inflame,  adhere,  thicken,  and  obliterate,  as  sound 
parts  do.  In  dissecting  an  agtd  subject,  we  always  find  the  ar- 
teries less  pliant,  sometimes  they  are  contracted,  sometimes  en- 
larged, they  become  white,  and  their  coats  thickened  and  less 
connected  with  each  other,  separate  like  the  coats  of  an  onion 
into  ten  or  twelve,  or  into  innumerable  lamelhe  ;  they  are  at  the 
same  time  brittle,  and  fragile,  and  have  a  crisped  feel;  they  are 
sometimes  ossified  ;  they  break  or  crack  when  we  attempt  to 
bend  th<-m  ;  and  the  drawing  ot  a  ligature  round  such  an  artery- 
tears  it  trom  want  of  pliancy ;  our  anatomical  injections  are 
successful  onlv  in  very  young  subjects  ;  while  in  older  subjects 
the  arteries  burst  because  thev  have  lost  their  strength  ;  or  tear 
under  the  necessary  ligatures  because  they  have  lost  their  plian- 
cy ;  the  anatomist  knows  by  the  first  touch  of  the  femoral  ar- 
tery, for  example,  whether  his  subject  will  bear  to  be  injected, 
and  the  surgeon  in  like  manner  often  foresees  by  the  first  touch 
of  his  finger,  those  burstings  of  the  artery  and  secondary  hae- 
morrhages of  which  so  many  have  died. 

Thus  it  often  happens,  that  the  artery,  too  hard  to  bear  a  li- 
gature, breaks  and  tears  across  in  the  very  moment  of  drawing 
tht  ligature  ;  the  artery  must  no  doubt  have  been  in  this  condi- 
tion, which  gave  the  celebrated  Petit  so  much  trouble  and  anxi- 
ety in  the  casi  ol  Mr.  Seneuze  the  bookseller.  Mr.  Petit  hav- 
ing amputated  this  gentleman's  thigh,  found  that  the  femoral  ar- 
ter j  was  nothing  affected,  neither  by  the  tourniquet  nor  by  the 
ligature  ;  and  he  was  obliged  in  the  end  to  suppress  the  hsemorr- 
hagy  by  compresses  piled  upon  the  face  of  the  stump,  and  bra- 
ced down  with  very  firm  rollers.  It  must  also  have  been  an 
artery  of  this  kind,  by  the  bursting  of  which  Mr.  Acrell  had 
almost  lost  his  patient ;  for  the  artery  did  not  stand  the  ligature 
one  moment,  but  in  a  manner  burst  under  his  fingers !  The  case 
is  as  follows  : 

tt  A  soldier,  of  a  scorbutic  habit,  extremely  weak  and  conva- 
lesce nt,  was  stabbed  unfortunately  with  a  pointed  knife  in  the 
femoral  artery,  about  seven  inches  below  Poupart's  ligament ; 
and  the  wound  bled  so  furiously  that  he  fainted :  a  physician, 
who  was  called,  bound  it  up  so  effectually  with  compress  and 
buncUge,  that  he  stopped  the  bletding  lor  twelve  days  ;  but  the 
blood  burst  out  again  on  the  thirteenth  day ;  notwithstanding 
which,  the  outward  wound  healed,  the  aneurismal  tumour  was 
distinctly  formed,  and  by  the  twentieth  day  it  beat  very  strong- 
ly, threatening  rupture.  Acrell  thinking  the  aneurism  too  large 
to  be  cured  by  compression,  proposed  to  tie  the  artery;    he 


Of  Ulceration  of  the  Artery.  51 

opened  the  tumour ;  sco  p^d  and  washed  out  the  very  black  and. 
fetid  blood,  and  exposed  the  artery,  which  he  found  dilated  for 
about  four  inches  into  a  large  sac  of  about  three  quarter?  of  an 
inch  in  diameter.  H-  then  tied  tht  arterj  with  one  ligature 
above,  but  behold  while  he  was  drawing  the  lower  ligature,  the 
artery  suddenly  burst  above  the.  upper  ligature,  and  threw  out  its 
blood  with  such  force,  that  in  less  than  a  minute  the  man  had 
lost  fully  four  pounds  of  blood."  This  art-  ry  tore,  under  the  pres- 
sure of  the  ligature  ;  the  tourniquet  could  not  command  tlte  hae- 
morrhagv  ;  the  ligature  itseit  was  in  em  ctual.  In  thes;-  distres- 
sing circumstances,  Acrell  at  last  suppressed  the  hamiorrhagy 
by  sponges  and  compression  !  with  these  he  "filled  up  tht  whole 
cavity  ol  the  aneurism  ;  and  to  ensure  a  proper  compression, 
he  made  a  sheath  for  the  thigh,  of  w  lute  iron,  with  a  g'obular 
compress  upon  its  internal  surface,  adapted  to  the  place  of  the 
wounded  artery."  Thus  he  accomplished  the  cure,  and  the 
case  is  a  singular  example  of  the  artery  in  that  very  state  which 
I  have  described  breaking  tinder  the  ligature,  giving  way  in 
the  very  moment  ol  the  operation. 

SECTION    v. 

Of  bursting  of  the  Artery  from  ulceration  of  its  Coats. 

Yet  it  is  not  to  this  unhealthy  condition  of  an  art<  ry  alone 
that  I  ascribe  the  deatti  of  those  who  have  perished  from  secon- 
dary haimorrhagy.  The  diseased  state  of  the  arteries  never 
can  explain  the  difference  of  danger  in  the  two  operations  of 
aneurism  and  amputation.  In  amputation  of  the  thigh  we  tie 
the  great  femoral  arttry ;  we  tie  also  the  profunda,  and  its  mus- 
cular branches  ;  wc  perform  amputation  daily,  and  we  tie  ma- 
ny great  arteries  in  each  amputation ;  each  ligature  is  seen 
moved  and  raised  up  from  the  face  of  the  stump  at  even  pulse 
of  the  artery  ;  the  stump  remains  open.  These  arteries  conti- 
nue for  weeks  to  bear  the  whole  force  of  the  circulation,  unsup- 
ported, yet  they  rareh  give  way. 

But,  in  the  operation  for  aneurism  of  the  thigh,  the  differ- 
ence of  security  is  very  great;  for  this  operation  is,  on  the 
other  hand,  so  full  of  uncertainty  and  danger,  that  hardlv  any 
case  can  be  mentioned  in  which  the  surgeons  have  not  been 
alarmed,  and  the  patient  in  great  danger,  from  secondary  hae- 
morrhages :  it  is  an  operation  never  performed  but  by  surgeons 
of  the  first  eminence  ;  and  \et  more,  perhaps,  have  died  than 
have  survived  it*.     Hunter  h'unself  has  lost  his  patients:  those 

*  The  fuccefs  attending  this  operation  has  been  much  greater  of  late.     S. 


52  Of  Ulceration  of  the  Artery. 

whom  be  did  save  were  endangered  by  secondary  haemorrha- 
ges; and  tile  celebrated  Mr.  Pott,  from  the  ill  success  of  one 
operation,  was  forced  to  amputate  the  thigh.  It  b.  hoves  us 
then  to  inquire,  What  the  difference  is  betwixt  tying  the  lcmo- 
ral  arterv  in  aneurism,  an  operation  so  lull  of  difficulty  and 
danger,  and  tying  the  same  artery  in  amputation,  an  operation 
which  is  so  perfecth  safe,  that  the  death  oi  a  patient  b)  haemorr- 
bagv  alter  it  would  b«  a  flagrant  disgrace. 

Secondary  H.tMOiNiHAGY  arises  from  Ulceration  of  the 
Artkry  more  frequently  than  from  any  other  cause.  In  am- 
putation, such  ulceration  rarely  happens,  except  when  the  liga- 
tures, having  been  firmly  tied  round  the  nerves,  are  prevented 
from  slipping  off,  or  when  the  whole  surface  of  the  stump  falls 
into  disease,  and  is  eroded  ;  but  in  aneurism  it  is  peculiarly  fre- 
quent, from  the  manner  in  which  a  great  length  of  the  artery  is 
insulated  and  detached  from  the  surrounding  parts.  It  the  sur- 
geon, forgetting  how  slight  a  force  suffices  for  suppressing  the 
pulse  of  a  naked  arterv,  and  tor  laying  its  sides  in  contact,  pulls 
his  ligature  with  all  the  firmness  which  the  artery  can  bear,  al- 
though the  artery  be  not  immediately  cut  across,  its  coats  may 
be  twisted  and  weakened;  or,  though  not  even  weakened,  they 
may  be  so  violently  compressed  that  not  only  the  portion  of  the 
tube  intercepted  between  the  two  ligatures,  but  the  part  imme- 
diately under  each  ligature  will  fall  directlv  into  gangrene  in 
place  of  adhering,  so  that,  on  the  third  day,  when  the  ligature  is 
withdrawn,  it  may  bring  along  with  it  the  end  of  the  artery*. 

It  the  surgeon,  in  place  of  dissecting  the  rjtery  fairly,  passes 
his  needle  under  it,  and  includes  much  of  the  muscular  sub- 
stance, or  other  soft  parts,  there  is  little  pressure  upon  the 
artery,  there  is  no  adhesion  of  it  under  the  ligatures,  there  is 
no  amputation  of  its  intercepted  part,  the  cellular  substance 
and  muscular  flesh  fade  and  give  way  on  the  third  or  fourth 
day :  But  the  artery  itself  is  still  entire,  and  the  blood,  by  this 
slackening  of  the  ligatures,  passes  along  the  canal  of  the  artery, 
and  out  at  the  wounded  point;  and  as  the  structure  of  the  artery 
is  but  little  affected  by  so  slack  a  ligature,  the  artery  continues 
entire,  the  ligature  keeps  its  place  round  the  artery,  and,  though 
it  does  not  compress  the  artery,  it  irritates  it,  and  is  never  dis- 
engaged till  the  arttr)  falls  into  ulceration  and  bursts. 

It  the  surgeon  should  pass  his  needle  anv  considerable  dis- 
tance from  the  vessel,  he  will  include  not  flesh  only,  but  will 

*  From  the  r.bfervationsof  Dr.  Jones,  it  would  appear  that  there  is  not  fo  much 
danger  to  be  apprehended  from  drawing  the  ligature  with  a  confiderable  degree 
of  tightnefs  as  Mr.  Bell  feems  to  fuppofe.  The  ligature  ought  to  be  tied  tight 
enough  to  divide  the  two  internal  coats  of  the  veffel,  and  the  furgeon  had  better 
err  on  that  fide,  than  incur  any  rifk  of  having  the  ligature  thrown  off.     S. 


Of  Ulceration  of  the  Artery. 

take  the  nerve  into  the  loop  of  his  ligature  !  for  every  great  ar- 
tery has  a  great  ntrve  of  the  limb  accompanying  it,  the  bra- 
chial artery  has  the  great  radial  nerve,  the  femoral  artery  has 
the  gr<  at  anterior  crural  nerve,  the  great  artery,  nerve,  and  in- 
ternal veins  of  each  limb,  lie  in  a  peculiar  sheath,  and,  in  order 
to  tie  the  artery  apart  irom  the  vein  and  nerve,  it  is  necessary 
to  dissect  this  peculiar  sheath  of  cellular  substance.  Now,  au- 
thors have  always  talked  slightly  of  tying  the  nerve,  as  it  the 
tying  it  related  only  to  the  nerve  itsell !  No  !  it  relates  to  the 
security  of  the  artery!  an  artery,  tied  with  a  ligature,  is  de- 
stroyed in  a  few  davs,  but  a  nerve  tied  with  a  ligature  is  hardly 
affected  by  it:  The  nerves  are  peculiarly  strong,  their  coats 
hard  and  firm  ;  a  ligature  tied  round  a  nerve  and  artery  toge- 
ther, as  it  cannot  destroy  the  nerve,  keej;s  its  hold  upon  the 
arterv,  till,  by  the  irritation  of  die  ligature,  and  other  obvious 
causes,  it  ulcerates  and  bursts  ;*  or,  it  this  can  be  prevented,  it 
is  only  by  cutting  the  ligature  timeously  away,  which  cannot 
be  done  without  a  degree  of  difficulty  and  danger. 

But  there  are  still  other  causes  ot  the  ulceration  of  arteries. 
If  the  surgeon,  anxious  to  insure  the  obliteration  of  the  arterv, 
resolves  to  lay  a  considerable  length  of  the  sides  ot  it  in  con- 
tact, what  does  he  do  but  insulate  the  artery,  tear  it  up  from 
its  bed  among  the  cellular  substance,  separate  it  lrom  all  those 
vascular  connections  which  kept  it  alive  !  he  exposes  it  to  al- 
most inevitable  ulceration!  This  has  been  practised  upon  the 
femoral  artery  in  a  great  variety  oi  ways,  all  of  them  ingenious, 
but  all  in  direct  opposition  to  the  principles  of  surgery.  These 
contrivances  lor  insulating  the  artery  are  sure  to  cause  that 
ulceratiuii  which  too  many  natural  causes  conspire  to  produce; 
and  it  is  this  ulcerated  state  of  the  artery  that  makes  it  neces- 
sary to  apply  successive  ligatures,  and  the  same  causes  make 
these  ligatures,  in  their  turn,  give  way.  As  far  as  possible 
then,  to  avoid  insulating  the  vessel,   I  would   tie  it  clear  of  the 

»  The  following  experiment,  which  is  extracted  from  Jones,  p.  1 79,  very  re- 
markably confirms  what  is  Gated  111  the  text. 

"  In  the  month  of  September,  1756,''  fays  Pouteau, "  I  tied  the  crural  artery 
of  a  dog  of  moderate  fize  with  a  ligature,  which  likcwife  included  the  nerve  of 
the  fame  name;  the  artery  was  not  opened,  and  the  animal  was  kit  to  itlelf.  On 
the  lourth  day  there  lupervened  an  haemorrhage,  which  ftnppedof  its  own  accord  : 
on  thi  'ie\t  day  it  recurred,  and  was  fo  profufe  that  the  animal  died.  Upon  lay- 
ing open  the  arter)  lengthwife,  I  found  it  open  at  its  anterior  part,  immediately 
under  the  thread  of  the  ligature  ;  there  was  in  its  cavity  a  clot  oi  a  pale  red  colour, 
of  a  moderate  conflftence,  and  in  the  form  of  a  fpindle  :  the  fuperior  extremity  oi 
the  coa^ulum  iloated  in  the  artery  above  the  ligature  ;  the  middle  portion  Was 
lighily  attached  to  the  poUerinr  part  01  the  artery  under  the  ligature  ;  the  inferior 
portion,  which  was  the  moft  (lender,  floated  in  the  artery  below  the  ligature  ;  thia 
coagulum  was  about  four  lines  in  lcng:h,  and  lefs  than  a  line  in  diameter,  at  it» 
thickeft  part."     Pouteau  Melanges  de  Lhirurgie,  p.  80.— S. 


54  Of  Aneurisms. 

nerves,  which,  being  indestructible,  hold  the  ligatures  too  long  : 
I  would  also  have  it  clear  of  the  muscular  flesh,  which  pre- 
vents the  ligature  from  having  its  full  effect  upon  the  artery  ; 
and  with  a  ligature  smaller  than  the  one  commonly  used,  I 
would  tie  the  vessel,  with  moderate  firmness,  as  near  as  possi- 
ble to  the  sound  parts. 

CONCLUSION. 

Thus  have  I  endeavoured  to  investigate,  in  a  general  way, 
the  causes  of  secondary  hxmorrhagy  :  I  ascribe  the  most  dan- 
gerous bleedings,  both  in  amputation  and  in  aneurism,  to  the 
ulceration  of  the  great  artery  :  some  of  the  causes  I  hope  I 
have  explained  to  your  satisfaction  ;  and  the  practical  conclu- 
sion, which  1  would  deduce  from  this  doctrine,  is  of  no  small 
importance  :  it  has  relation  more  or  less  directly,  to  every  great 
operation ;  and  therefore  reflect,  I  beseech  you^  on  those  facts 
and  principles,  and  judge  for  yourselves.  It  is  my  opinion, 
that  a  great  artery  never  can  be  safe  while  the  ligature  remains 
about  it  ;  for,  till  it  comes  away,  the  artery  cannot  be  said  to 
have  adhered,  cannot  be  buried  in  granulations,  nor  supported 
by  the  surrounding  flesh,  cannot  be  out  of  danger  of  ulcera- 
tion. Nor  can  a  great  artery  ever  be  safe  while  it  remains  in- 
sulated :  surg-ons  seem  to  take  a  pleasure  in  seeing  it  lying 
fairly  along  in  the  cavity  of  an  aneunsmal  sac  ;  but  they  should 
recollect,  that  if  the  artery  lies  more  within  the  reach  of  an  ope- 
ration, it  is  also  surer  to  need  it  ;  for  being  thus  stripped  of  its 
cellular  substance,  deprived  of  its  nutritious  vessels,  the  part 
which  is  included  betwixt  the  two  ligatures  must  gangrene  ;  the 
parts  under  the  two  ligatures  often,  in  place  of  adhering,  will 
ulcerate  ;  the  ulceration,  in  place  of  stopping  when  the  ligatures 
fall  off,  will  continue  ;  and  as  the  artery  is  a  firm  part,  enter- 
ing slowly  into  disease,  it  ulcerau  s  slowly,  and  bursts  only  on 
the  tenth,  twelfth,  or  fifteenth  da\  .* 

*  Vide  Appendix  C. 


(     55      ) 

DISCOURSE  V. 

OF  ANEURISMS. 

Descriptions  of  Aneurisms. 

ZxNEURISM,  when  it  arises  without  blow  or  hurt,  steals  on 
slovvh.  A  small  tumour  is  felt,  for  instance,  in  the  ham ;  it 
is  small  at  first,  and  firm,  and  but  little  affected  by  die  pulsation 
of  the  artery.  It  lies  deep  among  the  fiVsh,  and  must  be  telt 
for  bv  working  in  the  fingers  and  pressing  aside  the  adjacent 
parts.  It  is  supposed  to  be  a  knot  or  kernel,  has  little  pain,  is 
neglected  for  many  weeks,  and  might  be  mistaken,  even  by  a 
surgeon,  for  a  swelled  gland  These  tumours  begin  during 
sickness  and  convalescence,  w  hile  the  patient  is  in  a  state  ot 
perfect  quiet,  and  while  there  is  not  even  the  slightest  fever  to 
account  for  this  dilatation  of  the  artt  ry ;  but  it  doubts  concern- 
ing its  nature  remain,  we  gent  rally  find  them  all  resolved  by 
the  dissection  of  the  body.  These  aneurisms  are  lound  to  be 
true  dilatations  of  the  artery  ;  there  is  no  breach  of  the  arterial 
coats,  the  cellular,  the  muscular,  the  villous  coats  are  thickened 
as  they  approach  the  dilated  part,  and  may  be  fairly  traced 
over  the  aneurismal  tumour*  ;  it  is  on  the  tumour,  indeed,  that 
the  several  coats  are  most  distinctly  traced.  But  strong  as  this 
predisposition  is,  we  are  astonished  to  find  these  dilatations  end 
gradually  and  gently  in  the  sound  artery,  which  has  in  the  in- 
termediate parts  not  the  slightest  mark  of  disease,  the  arterial 
system  being  throughout  limber,  soft,  and  natural. 

But  aneurism  arises  not  only  from  this  inscrutable  predispo- 
sition, but  often  from  an  actual  and  manifest  disease  of  the  ar- 
terial system.  We  frequently  find  throughout  the  arterial  sys- 
tem, the  coats  of  the  arteries  thickened  and  brittle,  their  cellu- 
lar substance  loose  and  spongy,  with  spots  and  specks  of  ossifi- 
cation besetting  the  great  arterial  trunks. t  We  find  the  great 
arteries  dilated  where  they  give  off  their  larger  branches,  and 

•  Vide  Appendix  D. 
f  Scarpa  is  of  opinion,  that  fpontaneous  aneurifms  generally  proceed  from  what 
he  calls  a  "  flow,  morbid,  ulcerated,  fteatomatous,  fungous,  Iquamous  degeneration 
of  the  internal  coat  of  the  artery  ;"  for  which  he  cites  numerous  authorities.     S. 


56  Of  Aneurisms. 

the  arch  of  the  aorta  or  beginning  of  the  subclavian  arteries  in 
an  aneurismal  state,  while  the  lower  part  of  the  aorta  is  small, 
crooked  and  irregular.  These  arc  the  marks  of  a  disease 
which  prevails  towards  the  decline  of  life  ;  it  is  often  observed 
before  the  fortieth  year;  but  it  is  singular,  that,  till  the  approach 
of  that  period  of  life,  natural  aneurisms  are  extremely  rare  : 
Aneurisms  are  rare  in  women  :  they  are  frequent  in  strong  and 
hard-working  men ;  but  in  them  also  they  rarely  occur  till  alter 
the  thirtieth  year,  when  their  arteries  begin  to  acquire  this  hard 
and  rigid  condition.  The  defects  of  old  age  come  upon  the 
arteries  sooner  than  upon  the  rest  of  the  system :  the  arteries 
are  unequal  to  those  exertions  of  which  the  muscular  frame  is 
still  capable  :  one  part  of  the  system  is  weakened  betore  an- 
other, which  is  the  very  essence  of  disease,  or  predisposition 
to  disease. 

Yet  this  predisposition  is  of  such  a  nature,  that  it  seldom 
degenerates  into  aneurism,  without  some  direct  violence  ;  and 
there  are  lew  of  those  enlargements  of  the  artery  which  cannot 
be  distinctly  traced  to  some  external  injury,  some  blow,  sprain, 
fall,  or  violent  exertion  of  the  limb.  There  are  few,  indeed* 
that  do  not  immediately  and  perceptibly  follow  the  injury.  Of- 
ten, I  am  persuaded,  the  artery  is  not  merely  injured,  but  ab- 
solutely burst  or  broken  across!  Aneurism  of  the  ham  is  more 
frequent,  in  consequence  of  the  artery  at  that  part  lying  close 
under  the  knee-joint,  and  bound  down  by  the  heads  of  the  gas- 
trocnemii  muscles,  whence  it  is  endangered  by  every  sudden 
motion  of  the  joint,  and  affected  by  every  strain  of  the  limb. 
Aneurism  is  frequent  also  in  the  thigh,  in  consequence  of  the 
length  and  great  size  of  the  femoral  artery,  its  oblique  course 
round  the  thigh,  its  passing  through  the  tendon  of  the  triceps, 
and  from  the  manner  also  in  which  it  is  braced  clown  by  the 
muscles.  The  operation  of  these  various  causes  of  laceration 
must  next  be  explained. 

An  artery,  such  as  I  have  just  described  it,  rigid  and  dis- 
eased, an  artery  which  tears  under  the  surgeon's  ligature,  which 
bursts  upon  injection,  which,  in  dissections,  feels  so  palpably 
hard  and  brittle,  is  surely  not  calculated  to  resist  violent  strains, 
or  sudden  motions  of  the  joint ;  and  accordingly  we  sometimes 
find  an  artery  perceptibly  lacerated  by  external  violence  and 
sudden  bending  of  the  joint,  just  as  it  might  be  broken  across 
with  the  finger  and  thumb  in  dissection. 

"  Three  years  ago,"  says  Walther,  "  I  had  the  long  wished- 
for  opportunity  of  dissecting  an  aneurismal  limb.  An  old  man, 
about  fifty  years  of  age,  of  a  constitution  naturally  hale  and  vi- 
gorous, was  confined  to  his  bed,  crooked  with  rheumati&m, 
and  tortured  with  pains  in  his  knees  j  his  left  knee  especially 


Of  Aneurisms.  57 

gave  him  great  distress.  This  miserable  creature  being  wretch- 
edly poor,  instead  of  sending  for  better  assistance,  applied  to 
an  old  woman,  who,  having  first  extended  his  crooked  knee 
very  violently,  wrapped  it  up  in  some  of  her  plasters.  This 
extension  of  his  knee  was  extremely  painful  to  him,  and  he  soon 
perceived  a  small  tumour  upon  the  popliteal  artery;  it  pulsated 
very  strongly,  and,  upon  the  slightest  pressure,  produced  ex- 
quisite pain.  This  aneurism  gradually  increased  to  an  enor- 
mous size  ;  and  it  was  only  when  the  poor  man  became  sensi- 
ble of  having  no  other  chance  for  life,  that  he  submitted  to 
amputation." 

"The  limb  was  immediately  carried  to  Walther's  rooms, 
where,  upon  dissection,  it  was  found  that  the  popliteal  artery- 
was  dilated  into  an  aneurismalbagof  a  heart-like  shape,  of  three 
inches  broad,  and  four  inches  long,  occupying  the  main^artery 
from  a  little  below  where  it  gives  off*  its  two  upper  articular  ar- 
teries, to  within  an  inch  of  that  point  where  it  divides  into  the 
tibial  and  fibular  arteries.  The  heads  of  the  gastrocnemii,  so- 
lasi,  and  plantar  muscles,  where  they  covered  the  sac,  were  ex- 
tended to  a  remarkable  degree  of  thickness  ;  and  the  great  vein 
and  nerve,  raised  by  the  tumour,  were  protruded  betwixt  the 
two  heads  of  the  gastrocnemii  muscles,  so  as  to  be  in  close  con- 
tact with  the  skin." 

In  the  drawing  of  this  aneurism  by  Walther,  which  is  in- 
deed very  beautiful,  we  see  osseous  concretions  occupying  the 
coats  of  the  tibial  and  fibular  arteries  below  the  aneurism.  We 
have  every  reason  to  presume,  that  in  the  ham,  and  in  the  up- 
per parts  of  the  femoral  arteries,  these  specks  of  ossification 
must  have  been  much  broader  and  more  frequent.  These  os- 
sifications are  the  surest  marks  of  this  brittle  unyielding  state 
of  a  great  artery.  An  artery  must  like  the  ligaments  and  other 
parts,  where  the  joint  continues  for  any  length  of  time  thus 
crooked  and  stiff,  be  proportionablv  shortened,  and  in  this  brit- 
tle state  must  be  unfit  to  bear  sudden  extension.  In  this  in- 
stance, some  of  these  brittle  ossifications  had  given  way,  or 
hurt  the  adjoining  parts  ;  the  remaining  coats  of  the  artery  had 
dilated  into  a  true  aneurism  ;  the  artery  certainly  had  been  in- 
jured, though  not  entirely  lacerated,  for  the  drawing  repre- 
sents a  true  aneurism,  a  sac  entire  and  continuous  with  the 
arterial  coats.* 

In  natural  aneurisms  we  see  the  slow  dilatation  of  an  arte- 
ry. But  when,  as  it  often  happens,  a  man  in  the  very  time  of 
billing,  or,  in  the  instance  of  a  blow,  or  sprain,  feels  pain  in  the 

*  It  is  much  more  probable  that  in  this  cafe  the  coats  of  the  artery  were  rup- 
tured, notwithftandinc;  the  appearance  represented  by  the  drawing. — S. 

H 


58  Of  Aneurisms. 

ham,  when  he  observes  that  he  has  from  that  moment  consi- 
derable pain  in  laying  his  leg  across  :  when,  on  the  third  or 
fourth  day  he  feels  distinctly  the  pulsation,  pain  and  lameness, 
which  are  the  peculiar  signs  of  aneurism,  what  reason  can  there 
be  for  doubting  that  the  artery  is  burst  i  None,  surely,  but  the 
slowness  with  which  the  aneurism  grows.  The  slow  manner, 
then,  in  which  even  the  greater  arteries  of  the  body  form  their 
aneurism,  must  next  be  explained. 

We  are  naturallv  inclined  to  believe,  that  an  artery  thus  bro- 
ken or  lacerated,  must  form  its  aneurism  the  mom'  nt  its  coats 
give  way,  and  must  be  able  to  overcome  all  resistance  from  the 
surrounding  parts  in  a  few  days.  But  here  we  are  deceived  ;  we 
must  not  regard  the  artery  as  a  naked  and  insulated  tube,  such 
as  is  represented  in  Figure  1st,  merely  laid  along  the  limb,  un- 
connected with  the  surrounding  parts,  unsupported  by  cellular 
substance.  The  artery  has  a  cellular  coat  in  which  it  is  lodged  : 
this  coat  is  so  peculiar  as  to  be  called  the  sheath  or  capsule  of 
the  artery,  and  is  closely  connected  with  the  proper  coats  of 
the  artery  by  cellular  substance  and  numerous  vessels,  which 
strengthen,  support,  and  nourish  it ;  and  when  the  proper  coats 
of  an  artery  are  torn,  the  blood  is  not  widely  extravasated,  but 
is  confined  by  this  sheath  of  cellular  membrane,  which  is  very 
slowly  forced,  or  separated  from  the  artery.  Even  after  the 
sheath  is  separated  from  the  artery,  it  does  not  entirely  give 
way,  but  its  cellular  substance  is  kneaded  as  it  were  with  the 
half  coagulated  blood,  and  rises  into  a  tumour  somewhat  re- 
sembling the  thrombus  which  rises  over  an  ill  closed  vein. 

Fig.  2d  represents  the  true  and  natural  condition  of  the  arte- 
ry which  is  every  where  nourished  by  its  cellular  sheath,  and 
represents  a  laceration  or  rupture  of  the  artery,  showing  how 
the  sheath  and  cellular  substance  are  opposed  to  the  exit  of  the 
blood. 

Fig.  3d  represents  the  aneurism  already  beginning  to  form. 
Here-  is  once  more  represented,  the  continued  sheath, 
within  which  the  great  artery  is  enclosed  ;  large  branches, 
such  as  the  profunda  femoris,  and  smaller  muscular  twigs, 
are  seen  going  off  from  the  great  trunk,  each  having  its  own 
peculiar  sheath.  For  the  smallest  arteries  are  as  well  support- 
ed with  cellular  substance,  and  have  sheaths  as  peculiar  as  the 
femoral  or  carotid  arteries  ;  each  little  artery,  as  it  penetrates 
among  the  muscles,  is  enclosed  along  with  its  corresponding- 
vein,  and  often  with  a  small  twig  of  a  nerve,  in  a  peculiar  fascia. 
Aneurism  produced  by  the  bursting  or  laceration  of  an  artery 
dilates  slowly,  because,  the  continued  canal  of  the  artery  is 
still  open  to  the  blood,  the  cellular  substance  yields  very  slowly, 
the  blood  coagulating   in  hard  and  firm  clots,  walls  up  the 


Of  Aneurisms. 


59 


artery,  and  is  so  mixed  with  the  first  lamella;  of  the  cellular  sub- 
stance, and  is  so  firmly  clotted  as  to  make  a  strong  resistance. 
At  first,  while  the  blood  is  confined  to  its  natural  course,  the 
progress  of  aneurism  is  slow.  But  when  the  cavity  of  the 
aneurism  is  enlarged,  when  the  blood  In  gins  to  collect  there, 
and  the  circulation  becomes  irregular,  these  clots  give  way  from 
time  to  time,  and  by  exercise,  working,  or  accidental  excite- 
ments, there  is  from  time  to  time  a  new  impetus  against  the 
sides  of  the  sac  itself,  and  it  enlarges  ,  the  clots  which  line  the 
cellular  substance  become  bigger  and  firmer;  layer  is  added  to 
layer,  and  at  every  addition  of  this  kind,  the  fluid  contents  of 
the  aneurism  accumulate,  the  open  part  of  the  bag  enlarges,  and 
the  cellular  sheath  of  the  artery,  which  in  fact  corresponds 
with  the  sheath  in  Fig.  2d,  is  condensed  into  a  firm  aneuris- 
mal  sac,  which  gives  the  whole  tumour  sometimes  the  appear- 
ance of  a  spontaneous  and  natural  dilatation  of  the  artery  itself. 
Thus  there  is  formed  a  great  tumour  of  plotted  blood,  surround- 
ed with  a  firm  cellular  sac,  and  bounding  a  cavity  which  is  con- 
tinuous with  the  artery,  where  the  circulation  of  the  blood  is  ir- 
regular, and  often  accompanied  with  a  whizzing  noise. 


I .   The  Naked  Artery 
Artery, 


Sketch  explaining  the  Fascia  of  an  Artery 

1.    The  Sheathed  Arlcr\ 


}_.  false  Aneurism, 

Aneurism. 


W& ju^WMfi  /jr 


This  hard  and  firm  tumour,  rising  higher  and  higher  over  the 
artery,  begins  at  last  to  compress  the  canal  of  the  artery  itself; 
the  clots  sometimes  loosen,  fail  down,  and  almost  cboke  the 
current  of  the  blood  ;  the  limb  grows  cold  and  benumbed,  from 


60  Of  Aneurisms. 

the  compression  of  the  great  trunk,  and  it  swells  and  inflames 
from  the  enlargement  of  the  inosculating  arteries.  By  the  per- 
petual and  increasing  pulsation,  the  pressure  and  straitness  in- 
.  crease,  the  bones  are  spoiled  within,  and  the  integuments  are 
almost  destroyed  without ;  the  limb  is  sate,  for  the  inosculating 
arteries  are  enlarged,  yet,  when  the  tumour  hurts,  the  patient 
dies  from  the  bursting  of  the  main  artery,  and  the  immediate 
loss  of  blood. 

Thus  we  perceive  that  the  increase  of  such  an  aneurism, 
where  the  artery  is  absolutely  broken  across,  is  naturally  slow  ; 
that  the  resistance  is  uniformly  great ;  that  the  artery  does  not 
lie  as  in  our  preparation  glasses,  or  on  the  dissecting  table,  insu- 
lated and  unconnected,  but  is  surrounded  with  cellular  sub- 
stance ;  its  rupture  is  walled  up  with  coagulated  blood  ;  its  ca- 
nal is  open  to  the  circulating  fluids,  and  there  is,  for  a  long 
while,  a  firm  pulse  even  in  the  artery  which  is  desperately 
wounded,  provided  it  be  not  entirely  cut  across*. 

But  where  the  femoral  artery  is  not  merely  wounded,  but 
entirely  cut,  or  broken  across,  it  will  no  doubt  form  its  aneu- 
rism more  rapidly,  perhaps  in  three  weeks,  instead  of  three 
months,  as  happened  in  a  case  which  occurred  to  my  friend, 
Mr.  Harkness.     The  patient  was  master  of  a  small  trading 

*  Explanation  of  the  Etched  Plate. 

Aneurifm  proceeding  thus,  from  violence  done  to  the  artery,  is  very  eafily  dif- 
tinguiftud  from  that  which  proceeds  from  a  natural  dilatation  of  the  tube.  I  have 
given  this  fheet  oi  Etchings  to  explain  this  piece  of  Pathology. 

In  Figure  iff  is  feen  a  Femoral  Artery  where  the  dilatations  are  plainly  of  that 
kind  which  is  called  Natural  Aneurifmf,  the  dilatation  being  fpontaneous  and  gra- 
dual; and  in  this  (ketch  it  will  be  noticed,  that  lince  the  profunda  (a)  comes  off 
from  one  of  the  aneurifmal  facs,  had  that  fac  increafed  fo  as  to  become  a  formida- 
ble aneurifm,  had  the  operation  been  performed,  and  the  ligature  been  tied  above 
that  aneurifm,  the  inofculating  arteries  communicating  with  the  proiunda  would 
have  poured  their  blood  into  the  fac,  and  caufed  a  fecondary  hxmorrhagy  if  the 
fac  was  cut  open,  or  fet  it  a  pulfating  again,  if  it  was  left  untouched. 

in  Figure  2d  you  have  a  fketch  of  that  Aneurifm  which  !  have  been  juff.  de- 
ferring, where  the  old  woman,  by  her  violent  bending  of  the  knee,  injured  the 
artery,  and,  I  have  very  little  doubt,  broke  it  acrofs,  and  left  the  breach  in  the  arte- 
ry fuftained  only  by  its  external  coat  of  common  cellular  lublrance. 

In  figure  3d  you  have  another  fketch  of  an  Aneurifm,  which  was  operated  upon 
by  Mr.  Hunter.  The  man  died  fome  years  after,  the  artery  was  differed  out,  and 
the  following  circumftances  deferve  particular  notice  :  iff,  The  artery  (bb)  was 
offified  throughout  the  whole  length  of  the  thigh;  this  does  not  feem  to  have  been 
the  confequence  of  the  operation  merely,  tor  the  profunda,  which  was  not  touched 
by  the  ligature,  was  alfo  offifitd:  therefore  this  man's  fyftem  of  arteries  was  predif- 
pofed  to  this  rupture  of  the  arterial  coat-,  and  his  trade,  viz.  that  of  a  hackney- 
coachman,  exgofed  him  to  blows,  twills,  and  drains.  2dly,  The  aneurifmal  fac 
(c)  lay  altogether  upon  the  back  of  the  artery  ;  it  was  formed  all  on  one  fide,  as 
if  the  artery  had  given  way  on  one  fide ;  it  lay  fo  over  the  artery,  as  to  prefs 
flrongly  upon  it.  The  aneurifm  had,  in  fome  mialure,  the  appearance  of  a  fe- 
parate  bag,  it  was  oblong,  a  little  flattened,  and  like  a  hen's  egg,  and  coi.tained  a 
iolidcoagulum."     3dly,.  It  is  indeed  very  ir.terefling  to  obferve  the  irioK-Jaticnr. 

f  Vide  Appendix  E. 


[  /  /;///>//<</.,   ■■>   ■     /'//"/v/A      /// 


//,  ///Vo  //'-J 


/feat-  .  <f&. 


/<>,/.■; 


/Wfit7it/a  Plnmmt 


Ftm  9. 


;\ 


A"  Anrun.'m  of  tie  Aamyicm  MMtrier 
a rsArsj c/j/j  /Ae  A/tturi*ma/  S<mQ  ^ 
j ma//  O/si/fca/ivns  /us/  ie/eur/Ae 
Mated '/tarf.  c  /As  Titia/  Artert/ 


A  / \yb/i/m/  Artnirr  sm  fAu-A  Aat/ Arm  tjrSsryifsWorr 
Av  V //un/rr.H'Arrf  /Ae  o/ilft  rit/lun U'AlfA  Aaa/jim/lJ- 

•flr>trd /Ac  Ar/trrv/o  t/i/rjAon  u  seen  /t/  6  Tie  .r#ta// 
r**:'nt/<z/tn</    \r&rrr.'  rr-cr/rtnf  il/eod/fvm  tr&oye 
ar^t  rutmlrW re.  nme/ '  &/tc  /gtnpe  r nr>.tru/tr/t/*€j 
Ar<inc6    /rYT  n.*?*//?,  try  Mr  /d/oo^f*  i"Ac  Ar/rf  y  Ac  - 

-/err  ft  rtcrrvbec/ 1? 


A  ilti'l«Wfrtlf  sfrf/c  tY  /A*  Acmorni/  <isfcc-*: 
tWtrrr  a  Ac  /cfirtrwt/ a  .<-ucce/>t<m  «f  An- 
-curf/rrtt/    Sai  t,  r/  nite  t^~  rfiese   Sacs  obc* 
-neci.ani/  c  //ic  ftv/u ndcr  <*n<J  fts  6/nrrcA- 
-ts  ijetn?  ff'r trvm  f/ic ti/jb/-rm<>s/  .  Ijmmtif' 

=jmtr/    Sac. 


Of  Aneurisms.  61 

vessel  belonging  to  Borrowstounness  ;  a  very  stout  athletic 
man,  about  lorty  years  or  age.  Six  months  before,  he  had 
broken  his  thigh  bone  ;  the  fracture  was  healed,  but  had  been 
set  so  clumsily,  that  the  lower  end  of  the  broken  bone  project- 
ed upwards  like  a  trochanter.  The  whole  weight  of  the  body 
rested  very  obliquely  upon  the  thigh,  which  was  manifestly  in 
danger  from  future  accidents  ;  yet,  while  the  bones  continued 
united,  the  leg  was  strong  and  serviceable. 

One  day,  iii  loading  some  goods  into  his  vessel,  he  slipped 
his  foot  and  fell..  Though  this  limb  never  actually  touched 
the  ground,  the  callus  had  snapped  across,  the  bones  passed 
one  another,  and  the  femoral  artery,  partly  by  the  angle  which 
it  made  over  the  prominent  end  of  the  broken  bone,  and  partly 
by  the  sharpness  of  the  bone  itself,  was  torn  almost  entirely 
across.  Even  this  aneurism  did  not  increase  very  suddenly, 
and  never  acquired  a  very  great  size :  it  formed  for  itself  a  re- 
gular sac,  and,  moreover,  when  near  bursting,  lost  its  round 
and  circumscribed  form,  and  became  flat.  It  is  easy  to  ima- 
gine that  an  artery  in  these  circumstances  could  not  be  well  sup- 
ported by  its  cellular  substance  ;  for  the  bones  had  been  but 
lately  re-united  by  a  callus  ;  they  were  now  broken  again,  and 
all  the  surrounding  cellular  substance  destroyed  :  there  was  al- 
ready, as  it  were,  a  cavity  prepared  for  receiving  the  blood  of 
the  artery  ;  accordingly,  the  moment  the  man's  foot  slipped 
under  him,  he  felt  txtreme  pain  from  the  various  parts  which 
were  lacerated,  and  even  that  night  the  tumour  began  to  iorm. 
The  next  day  the  tumour  was  large,  and  pulsated  very  strong- 
ly j  and  in  a  few  days  its  pulsation  was  so  powerful  as  to  raise 
the  bedclothes.  But  from  the  time  in  which  the  artery  began 
to  be  resisted  by  the  thick  muscles  and  lascia  of  the  thigh  (for 
the  aneurism  lay  altogether  under  the  belly  of  the  vastus  inter- 
ims) it  hardly  increased  in  size  :  it  remained  quite  stationary 
for  a  fortnight  or  more  :  even  the  pulsation,  which  had  begun  to 

for  we  find  every  mark  of  great  activity  umong  the  imaller  arteries  of  the  thigh, 
to  fupply  the  want  of  the  trunk.  The  femoral  artery  is  indeed  obliterated  in  the 
thigh  at  (h  b),  but  for  fome  ipace  above  the  aneurifm,  as  at  (d),  the  eanal  is  again 
open,  and  receives  many  inoiculating  arteries  (e  e  t),  and  is  full  of  blood.  The 
popliteal  artery,  under  the  aneurifmal  bag,  is  fo  obliterated  that  the  lower  mouth 
of  the  artery  cannot  be  found.  At  (f  f)  the  popliteal  artery  become!  once  more 
pervious,  it  there  alfo  receives  many  inokulations  ;  by  thofc  inofculations  the  blood 
probably  came  down  both  from  the  profunda,  along  the  back  of  the  thigh,  and  alfo 
by  fhorter  inofculations,  joining  the  pervious  part  of  the  artery  above  the  aneu- 
rifm, to  the  continuation  of  the  artery  below  the  tumour  ;  e  e  e  marks  the  inoicula- 
ting arteries,  d  marks  the  pervious  part  of  the  artery  below  the  tumour,  and  f  the 
divifion  of  the  popliteal  artery  into  the  tibial  and  fibular  arteries  ;  g  marks  a  large 
>nd  curling  inoiculating  artery,  which  manileflly  has  borne  much  of  the  force  of 
the  circulation,  is  greatly  enlarged,  and  leems  to  have  taken  precedency  of  all  the 
other  inofculations;  h  h  h  mark  >  tin  great  crural  vein,  with  its  branchi  ■>  accompa- 
nying the  artery. 


62  Of  Aneurisms. 

be  very  powerful,  was  in  some  degree  deadened  by  the  accumu- 
lation of  blood,  and  the  pressure  of  the  surrounding  parts,  and 
somewhat  reduced  by  the  enlargement  of  the  collateral  arteries. 
The  limb  preserved  its  natural  heat  and  circulation  :  every 
thing  was  favourable  to  the  bold  attempt  of  saving  a  limb  at 
once  fractured  in  its  bones,  deprived  of  its  main  artery,  and 
loaded  with  a  great  aneurism.  This  operation  was  once  agreed 
to,  but  a  second  consultation  condemned  the  limb  to  be  cut  off: 
it  was  cut  off,  and  the  man  died. 

Thus  we  perceive,  that  even  the  great  femoral  artery,  al- 
though entirely  torn  across,  forms  its  aneurism  but  slowly. 
The  amputation  of  the  limb,  in  this  case,  was  performed  the 
fourth  week  after  the  fracture  of  the  bone  and  bursting  of  the  ar- 
tery, and  yet  the  aneurism  had  attained  but  to  a  moderate  size  : 
and  the  following  case  shews  that  even  when  the  aorta  itself 
bursts,  it  forms  its  aneurism  very  slowly,  and  does  not,  by  any 
means,  prove  immediately  fatal.* 

An  officer  of  distinction,  about  forty  years  of  age,  was 
wounded  in  the  battle  of  Fontenoy  ;  and  from  his  long  con- 
finement to  bed  he  fell  into  bad  health.  He  was  distressed, 
during  his  confinement,  with  nephritic  complaints,  and,  soon 
after  his  recovery,  was  seized  with  vomiting  and  spitting  of 
blood.  He  went  to  Bristol  Wells,  recovered  his  health,  and 
continued  for  nearly  ten  years  to  live  a  careful  and  regular  life, 
attentive  to  his  exercise  on  horseback,  to  his  diet,  and  to  the 
quantity  of  wine  he  drank. 

About  ten  years  after  these  complaints  he  seems  to  have 
been  suddenly  seized  with  very  inexplicable  distress,  which 
soon  ended  in  his  death.  He  began  first  to  complain  of  want 
of  rest,  tenesmus,  gripes,  and  mucous  stools  streaked  with 
blood.  These  symptoms  were  appeased  by  some  draughts  of 
oil,  manna,  and  rhubarb,  but  the  watchfulness  continued.  The 
patient  felt  more  than  usual  pain  in  his  belly,  especially  in  the 
left  side  ;  he  feared  a  return  of  his  gravellish  complaints,  and 
about  a  month  after  this  first  attack,  he  consulted  Sir  John 

•  Except  in  thofe  cafes  in  which  a  rupture  takes  place  in  that  part  of  the  aorta 
included  in  the  duplicative  of  the  pericardium,  in  which  event  death  immediately 
enfues.     Vide  Wimart's  Scarpa,  p.  81,  for  an  inftance,  and  citations  of  others.— S. 

Another  cafe,  which  is  an  exception  to  this  rule,  is  ilated  by  Mr.  B.  from  War- 
ner", who  relates  it,  apparently  from  memory,  in  lew  words,  but  very  deciiively  ;. 
the  general  impreffion  of  the  cafe  upon  his  mind  feems  to  have  been  very  ftrong. 
"  Some  years  ago  the  operation  for  aneurifm  was  performed  in  a  fimilar  cafe  with- 
in a  few  hours  of  the  rupture  of  the  veffel,  the  tumour  increafing  fo  fad:,  and  the 
pain  proving  fo  intolerable,  that  it  was  neceflary  to  lofe  no  time.  '1  he  tibialis 
poftica  was  burft  in  the  middle  of  the  leg  :  it  was  taken  up  with  fome  difficulty, 
and  the  patient  recovered.'' 

An  immediate  operation  is  the  only  means  of  faving  the  limb,  and  proba!  ly 
the  life  of  the  patient,  under  fuch  circumftances.—S. 


Of  Aneurisms.  65 

Pringle.  A  hiccup  had  come  on,  the  pain  was  now  constant, 
sharp,  darting  to  his  back,  groins,  and  testicles ;  it  was  especi- 
ally severe  when  he  turned  to  his  right  side,  but  he  never  at- 
tempted to  turn  upon  his  left.  These  were  the  decisive  marks 
of  some  organic  disease.  The  disorder  was  quite  unaccount- 
able. His  pulse  was  quicker,  harder,  and  fuller  than  natural. 
He  had  some  degree  ot  thirst,  but  his  head  was  clear.  Such 
was  the  degree  of  watchfulness,  that  for  six  weeks  he  had  not 
been  sensible  of  slumbering  half  an  hour:  for  the  last  three 
weeks  of  his  life  he  was  hardly  sensible  of  having  even  closed 
his  eyes.  His  feet,  he  observed,  were  sometimes  benumbtd, 
which  made  him  call  for  more  wine  than  usual ;  and  though  he 
had  no  sickness  at  his  stomach,  his  appetite  was  gone.  He 
was  bled,  but  as  he  grew  daily  weaker,  they  were  afraid  to  re- 
peat the  bleeding ;  and  for  his  hiccup,  he  took  musk  and  ab- 
sorbents, without  effect.  Opiates  were  not  omitted;  and  both 
on  account  of  the  hiccup,  and  in  order  to  procure  sleep,  lau- 
danum was  given  ;  at  first  in  smaller  doses,  but  his  physicians 
were  soon  obliged  to  give  it  to  the  amount  of  one  hundred 
drops  during  the  night,  without  checking  the  hiccup,  or  obtain- 
ing sleep;  but  it  raised 'a  general  perspiration.  He  seemed, 
after  this,  to  be  relieved  :  his  spirits  revived,  the  pain  ceased ; 
but  this  was  the  deceitful  prelude  to  death.  On  the  day  of  his 
death,  he  continued  all  the  morning  wide  awake,  sensible  and 
in  good  spirits,  but  with  an  incessant  hiccup.  About  four  in 
the  afternoon  he  called  for  drink  ;  but  before  the  servant  could 
warm  it,  he  suddenly  expired. 

The  dissection  of  this  gentleman's  body  proves  to  us  a  very 
unprecedented  fact,  that  the  aorta  itself  sometimes  gives  way  ; 
that  the  aneurism,  which  its  laceration  forms,  is  hardly  more 
rapid  in  its  growth  than  that  of  a  smaller  artery  ;*  that  the  sac 
which  it  forms  out  of  the  loose  cellular  substance,  is  firmlv  at- 
tached to  the  artery,  as  if  the  aneurism  had  arisen  from  mere 
dilatation.  The  abdominal  viscera  were  sound;  but  there  was 
a  tumour  larger  than  the  fist,  of  an  oblong  figure,  lying  close  to 
the  spine,  by  the  side  of  the  aorta  descendens,  and  in  the  direc- 
tion of  that  vessel.  It  began  as  high  as  the  emulgent  arteries, 
descended  nearly  to  the  pelvis,  and  was  of  a  very  firm  consist- 
ence. It  was  found  to  consist  of  coagulated  blood,  condensed 
in  the  cellular  substance,  and  under  the  adjacent  parts  of  the 
periosteum  were  some  detached  parcels  of  extravasation.    This 

*  The  rapidity  with  which  an  aneurifmal  tumour  enlarges,  depends  rather  up- 
on the  extent  of  the  breach  in  the  arterial  coats,  and  the  fituation  of  the  artery 
with  regard  to  the  furrour.ding  parts.  Thus  a  popliteal  aneurifm  niuft  neceffari- 
ly  increafe  flowly  from  its  confined  fituation  ;  whereas  an  anturifm  of  the  external 
•liac  artery  would  increafe  with  much  greater  rapidity,  from  the  oppofitr  caufe. — S. 


64  Of  Aneurisms. 

abdominal  portion  of  the  aorta,  along  with  its  tumour,  were 
dissected  out  ot  the  body,  together  with  a  part  of  the  thoracic 
aorta,  and  of  the  common  iliac  arteries,  and  the  middle  part  of 
the  aorta  being  laid  open  through  its  whole  length,  there  was 
observed,  in  the  space  between  the  e nmlgents  and  lower  me- 
senteric arteries,  a  complete  rupture  ot  all  us  coats.  The  aper- 
ture had  lacerated  edges  ;  was  big  enough  to  admit  the  point 
of  the  dissector's  thumb,  and  led  into  a  tumour,  which  now  ap- 
peared to  be  a  SPURIOUS  ANEURISM  of  the  GREAT  ARTERY; 
that  is,  a  sac  formed  of  the  cellular  membrane,  containing  blood 
of  different  degrees  of  coagulation,  which  apparently  had  issued 
at  different  times  from  the  aorta. 

The  neatness  of  this  dissection  prevents  all  those  doubts 
which  puzzle  us  in  cases  less  correcdy  related  ;  but  the  case 
is  written  by  Sir  John  Pringle  ;  the  dissection  was  performed 
by  Hunter :  the  tumour  was  not  first  mangled,  more  canino, 
and  then  the  connections  and  causes  of  it  stated  in  idle  conjec- 
tures. The  aorta  was  slit  up  on  that  side  which  was  sound. 
The  dissectors  saw  clearly  the  connection  of  the  tumour  with 
the  artery.  The  artery  was  burst,  the  laceration  had  ragged 
edges,  preventing  all  suspicion  of  previous  dilatation  ;  the 
breach  was  such  as  to  admit  of  the  dissector's  thumb,  and  was 
proportioned  to  the  size  of  the  artery.  The  sac  was  formed  in 
the  cellular  substance,  condensed  in  proportion  to  the  driving 
of  the  blood,  and  it  adhered  so  to  the  artery  as  to  be  cut  out 
along  with  it,  and  certainly  would  have  been  reported  by  less 
dexterous  dissectors,  as  a  natural  aneurism  which  had  burst. 
The  blood  was  collected  by  several  successive  extravasations ; 
the  artery  making  (according  to  the  exertions  of  the  body)  suc- 
cessive impulses  against  the  cellular  substance,  and  against  the 
peritoneum,  which  serves  as  the  sheath  for  this  vessel.  For 
our  entire  satisfaction  in  regard  to  the  nature  of  this  disease, 
we,  in  another  paragraph,  learn  also  the  cause,  for  "the  aorta 
was  not  dilated  above  the  aperture,  but  its  coats  were  at  that 
place  harder  than  natural,  as  if  tending  to  ossify,  and  having 
lost  their  natural  elasticity  and  toughness,  were  parted  asun- 
der."* 

Here  then  is  the  greatest  artery  of  the  body  burst ;  fairly 
torn   asunder,  and  that  without  any   strain  or  blow/f       The 

*  "  Upon  the  review  of  the  whole,  we  conclude  that  a  fmall  aperture  had  at 
Srft  been  made  at  this  weak  part  of  the  aorta,  fonie  confiderable  time  before  the 
death  oi  the  patient ;  that  the  tumour  had  been  gradually  formed  of  the  oozing 
of  the  blood  into  the  cellular  membrane  furrounding  the  artery,  and  which  there- 
upon was  dilated  into  that  fac  mentioned  above."  Vid.  Sir  John  Pringle's  Me- 
dical Effays  and  Obfervations  of  Edinburgh,  Vol    III. 

■f  Mr.  Elfe  obferves,  That  "the  arteries  fometimes  become  ruptured  without 
any  previous  dilation.     1  have  (fays  this  author)  a  preparation  of  the  aorta  afcen- 


Of  &Yieurism$.  oo 

greatest  artery  of  the  body,  not  supported  like  the  femoral  ar- 
tery by  a  peculiar  sheath,  nor  bedded  in  firm  cellular  substance 
o£  muscles,  but  merely  covered  by  the  peritoneum,  and  lodged 
in  the  loose  cellular  substance  of  the  kidney,  is  yet  so  supported 
as  to  form  its  aneurism  very  slowly.  The  blood  is  forced  in- 
to the  cellular  substance  by  successive  impulses.  The  sac  is 
fairly  circumscribed,  and  forms  an  oblong  tumour  not  much 
bigger  than  the  fist,  though  of  considerable  length,  lying  close 
to  the  side  of  the  artery,  and  so  connected  with  it  as  to  be  cut 
out  along  with  it:  well  may  such  a  sac  be  mistaken  tor  that  of 
a  natural  aneurism  in  bungling  dissections. 

Thus  have  I  proved  to  you,  that  an  artery  is  sometimes  dila- 
ted gradually,  sometimes  is  hurt  in  its  coats,  but  very  often  is 
burst,  lacerated,  or  entirely  broken  across*.  That  after  being 
burst,  it  is  supported  by  its  sheath.  That  the  cellular  substance 
receives  the  blood ;  while  the  breach  in  the  artery  thus  walled 
up  with  coagula,  forms  its  aneurism  slowly  ;  that  the  greatest 
arteries  of  the  body  form  their  aneurisms  slowly,  and  have  the 
cellular  substance  and  arterial  sheath  beaten  into  the  form  of  a 
distinct  sac  j  and  that  an  aneurism  which  truly  arises  from  a  la- 
ceration of  the  artery  may  be  mistaken  for  a  natural  aneurism  or 
simple  dilatation  of  the  tube  ! 


SECTION    II. 

Conclusion. — Containing  a  description  of  various  anomalous  ca- 
ses of  Aneurism. 

To  what  practical  uses  these  speculations  may  be  applied, 
you  will  next  inquire  ;  for,  unless  they  have  some  influence  on 
practice,  your  interest  in  them  should  be  but  very  small.  You 
will  remark  that  no  sooner  is  it  proved  to  you  that  an  artery 
may  be  burst  by  a  strain  of  the  limb,  than  you  begin  to  look 
upon  certain  accidents  which  are  apparently  trivial,  in  a  new 
and  serious  light.     In  the  case  of  a  direct  wound  of  an  artery, 

dens,  appearing  in  no  place  dilated,  which  exhibits  two  ruptures,  one  is  fmall,  and 
fuuated  about  halt'  an  inch  diftance  from  the  valves,  from  which  a  coagulum  was 
formed  about  the  fize  of  a  large  nutmeg,  that  was  feated  between  the  trunk  of  the 
aorta  and  the  trunk  of  the  pulmonary  artery.  From  trie  white  appearance  of  the 
coagulum,  and  the  regularity  of  the  edges  of  the  rupture,  it  fecmed  to  be  of  long 
(landing.  The  other  rupture  is  much  larger,  feated  :it  the  curvature  between  the 
exit  of  the  right  and  left  carotid  arteries,  the  edges  of  which  are  torn  and  irregular. 
and  lormed  a  tumour,  which  preffing  againft  the  lower  part  of  the  trachea,  and 
the  branches  of  the  bronchia,  deifroyed  the  patient  by  fuffocation  in  lets  fhan  a 
month  from  its  firft  rife,  and  before  there  was  any  appearance  of  an  external 
"welling. 

*  This  laft  is  probably  a  very  rare  occurrence.     S. 

I 


66      Description  of  various  anomalous  cases  of  Aneurism. 

succeeded  by  a  large  tumour,  with  strong  pulsation,  and  all  the 
characteristic  signs  of  pure  aneurism,  you  can  be  at  no  loss  to 
distinguish  the  nature  of  the  disease.  But  too  often  it  happens, 
that  when  this  disease  begins  in  a  sprain,  when  the  pain  is  great, 
the  pulsation  small,  and  the  whole  member  swelled  to  a  great 
size,  the  general  enlargement  conceals  the  particular  swelling  of 
the  aneurism,  and  the  limb  is  destroyed  before  the  surgeon  is 
aware  of  the  nature  of  the  disease.  These  are  the  cases  which  are 
so  generally  called  anomalous,  or,  in  other  words,  cases  which 
are  not  understood.  While  the  surgeon,  unwilling  to  believe 
that  an  artery  is  burst  by  a  sprain  of  the  limb,  remains  ignorant 
of  the  nature  of  the  disease,  the  artery  is  actually  ruptured,  and 
is  pouring  out  its  blood  among  the  muscles  ;  the  bones  are  pre- 
sently destroyed,  the  whole  limb  is  ruined  in  its  texture,  swell- 
ed, cold,  and  lifeless.  The  surgeon  cuts  it  off,  and  being  as  lit- 
tle expert  in  anatomy  as  judicious  in  surgery,  he,  upon  finding 
bones,  blood,  and  matter  mixed  in  one  confused  mass,  learns  by 
his  dissection  nothing  more  than  he  did  by  his  previous  inqui- 
ries :  he  calls  it  an  anomalous  case !  but  these  are  not  the  less 
aneurisms,  because  of  our  being  ignorant  of  their  nature  and 
origin,  and  of  that  process  by  which  they  come  to  this  last  stage 
of  irregular  suppuration. 

This  is  the  general  termination  of  neglected  aneurisms  ;  but 
there  are  certain  occasions  in  which  the  disease  infallibly  as- 
sumes this  form.  First,  Wherever  the  aneurism  is  produced 
by  a  broken  bone,  for  there  the  artery  is  wounded  or  broken  on 
the  side  next  the  bone,  the  blood  is  poured  out  under  the  bellies 
of  all  the  muscles,  the  resistance  to  its  outward  extension  is 
great,  and  the  inward  destruction  of  parts  is  proportionably  ra- 
pid. Secondly,  When  the  the  aneurism  happens  in  the  ham,  or 
under  the  bellies  of  the  gastrocnaemii  muscles,  for  there  the 
aneurism  is  peculiarly  straitened,  it  is  pent  up  betwixt  the  ham- 
string tendons,  it  forms  slowly,  is  singularly  hard,  and  frequent- 
ly has  neither  the  pulsation  nor  other  marks  of  aneurism  ;  but 
the  knee-joint  being  destroyed,  the  bones  corrupted,  and  the 
limb  enormously  swelled,  it  requires  amputation  long  before  the 
tumour  threatens  to  burst !  even  amputation  is  not  safe  !  Third- 
ly, But  most  of  all,  the  limb  is  in  danger  when  the  case  is  not 
understood  ;  when  the  artery  is  not  wounded, nor  gradually  di- 
lated, but  actually  burst ;  for  the  surgeon,  little  accustomed  to 
think  of  this  bursting  of  an  artery,  never  apprehends  the  true 
nature  of  the  complaint,  nor  even  knows  it  to  be  aneurism  ! 
After  having  amputated  the  limb,  his  exculpation  consists  in 
calling  it  an  anomalous  case,  intimating  that  it  was  unintelligible 
and  incurable. 


(     67     ) 


Of  Aneurism  from  Fracture  of  the  Bones. 

Aneurism,  from  fracture  of  the  bones,  is  more  or  less  impor- 
tant according  to  the  artery  that  is  wounded,  and  the  other  cir- 
cumstances of  the  case.  In  a  fracture  near  the  ankle,  the  artery 
is  small,  the  aneurism  superficial,  the  resistance  outwardly  is 
slight,  whence  the  bones  within  are  proportionablv  less  endan- 
gered. In  such  aneurism  behind  the  ankle,  in  the  Fibular  Arte- 
ry, for  example,  the  tumour  should  be  opened,  the  artery  tied,  and 
then  the  bones  re-unite,  but  till  you  have  tied  up  the  artery,  you 
have  in  general  no  re-union  of  the  bones.  We  find  that  this 
aneurism  also  grows  very  slowly,  insomuch  that  sometimes  it 
hardly  appears  till  after  the  callus  is  formed,  and  the  patient  be- 
gins to  walk.  There  are  indeed  exceptions  to  the  general  rule, 
for  the  fracture  sometimes  heals  while  the  aneurism  goes  on. 
11  A  surgeon  of  Guand,  being  called  to  set  a  broken  leg,  appli- 
ed the  usual  bandages,  and  in  the  usual  time  accomplished  the 
cure.  But  when  the  young  man  began  to  walk  abroad,  a  tu- 
mour was  observed  behind  the  ankle,  over  the  place  where  the 
bones  had  been  broken  ;  the  surgeon  (now  called  again)  being 
ignorant  of  the  nature  of  the  disease,  applied  a  caustic,  but  when 
he  opened  the  eschar,  instead  of  matter  which  he  expected, 
blood  gushed  out  so  impetuously,  that  it  was  stopped  with  great 
difficulty.  The  young  man  fainted  in  the  moment  of  this  hae- 
morrhagy,  and  expired  in  two  days  after*." 

When  the  artery  is  of  another  order,  larger  and  lying  deep 
among  the  muscular  flesh  close  upon  the  bone  by  which  it  has 
been  lacerated,  the  case  is  more  unfortunate,  and  if  neglected, 
too  frequently  terminates  in  mortification  and  death.  The  tu- 
mour caused  by  such  an  artery  is  large  and  diffused,  the  coagula 
of  blood  which  oppress  the  limb  are  very  large,  and  consequent- 
ly the  pulsation  is  not  distinct  and  smart,  but  heavy  and  throb- 
bing. Knowing,  as  you  do,  the  principles  of  Surgery,  you 
need  not  be  informed,  that  if  the  oppression  be  allowed  to  in- 
crease, the  limb  will  fall  into  gangrene,  or  the  skin  burst  and  the 
patient  bleed  to  death.  And  you  must  be  sensible,  that  if  the 
skin  be  left  to  burst,  you  must  then  search  for  the  artery  and 
tie  it,  with  but  a  poor  chance  of  success,  the  extravasation  hav- 
ing quite  ruined  the  texture  of  the  limb.     If  again  the  oppres- 

1  Palfin,  page  341.  This  is  a  rare  exception  to  the  general  rule,  that  fuch  com- 
plicated fracture  cannot  heal  till  after  the  artery  is  tied.  In  this  cafe,  prohably, 
the  artery  had  formed  a  fmall  fac  for  irfelf,  diftind  from  the  lacerated  cavity  fornv- 
■il  bv  the  fractured  bone*. 


68  Of  Aneurism  from  fracture  of  the  Bones. 

sion  be  allowed  to  increase  till  the  limb  become  generally  swell 
ed,  cold,  lifeless,  and  in  danger  of  gangrene,  you  must  cut  it  off, 
without  perhaps  the  consolation  of  saving  even  the  patient's  life, 
for  such  a  limb  is  apt  to  run  into  gangrene. 

When  an  artery,  then,  is  thus  lacerated,  along  with  frac- 
ture of  the  bones,  you  have  but  this  alternative  to  cut  the  limb 
off  at  once,  if  it  be  very  desperately  wounded,  or  to  try  to  save 
it  by  making  incisions  (as  in  simple  aneurism),  and  tying  the  ar- 
tery !  If  you  call  a  consultation,  it  is  not  to  decide  so  clear  a 
point,  but  to  satisfy  the  friends  and  exonerate  yourself.  The 
fracture  is  already  complicated  with  aneurism,  and  vou  are  un- 
der the  dangerous  necessity  of  converting  this  complicated  aneu- 
rism into  a  compound  tracture  !  You  apply  your  tourniquet, 
make  a  long  and  deep  incision,  turn  out  the  coagula  of  blood 
with  your  fingers,  cleanse  the  sac  with  sponges,  search  for  the 
artery  and  tie  it  upf.  You  wash  out  the  blood  from  the  sac 
with  syringes  and  sponges,  for  while  it  lies  betwixt  the  bones 
they  cannot  unite  ;  what  blood  you  are  forced  to  leave  melts 
down  into  bad  matter  and  flows  off ;  the  deeper  parts  of  the 
wound  gradually  digest,  granulate,  and  fill  up  with  soft  flesh  ; 
and  when  the  continuity  of  the  parts  is  thus  restored,  the  new 
bone  or  callus  begins  to  form.  Such  is  the  activity  of  a  wound- 
ed artery  in  forming  its  aneurism  and  destroying  the  surround- 
ing parts,  and  so  complicated  is  the  disorder  when  a  wounded 
artery  is  added  to  a  fractured  bone,  that  unless  these  operations 
are  performed  early,  the  limb  is  inevitably  lost. 

But  the  condition  of  the  periosteum  must  chiefly  be  regard- 
ed, for  being  part  of  the  system  of  the  broken  bone,  it  is  capable 
of  generating  new  bone,  and  the  form  of  that  bone  will  be  regu- 
lated by  the  parts  upon  which  it  may  be  moulded.  The  perioste- 
um being  now  expanded  into  the  form  of  a  cyst  over  the  broken 
bone  and  aneurismal  blood,  its  new  secretion  of  bone  will 
spread  over  the  aneurism.  The  outside  of  the  periosteum  is 
still  connected  with  the  muscles  and  other  soft  parts,  it  is  nou- 
rished and  receives  its  vessels  from  without,  and  lives,  and 
thickens,  and  begins  a  secretion  of  bone.  The  secretion  while 
it  is  in  this  unnatural  extended  condition  is  very  powerful,  and 
the  bone  which  is  formed  by  this  dilated  or  expanded  perios- 
teum, is  not  only  firm,  but  broad  like  a  scull.  We  often  see 
the  lacerated  periosteum  and  the  membranes  of  fractured  and 
luxated  joints,  or  of  carious  bones,  forming  great  bony  caries  or 
stalactite  like  projections.  In  gunshot  wounds,  with  fractures 
of  the  upper  part  of  the  thigh-bone,  in  the  scrophulous  caries  of 


f  For  more  particular  directions  for  taking  up  wounded  arteries,  vide  chapter  en 
Jiat  fubjed.     S. 


Of  Aneurism  from  fracture  of  the  Bones.  69- 

the  hip-joint,  in  luxations  of  the  thigh-bone  from  the  acetabu- 
lum, in  fractures  of  the  cervix  femoris,  in  compound  fractures 
and  luxations  of  the  wrist,  and  in  fractures  of  the  shoulder- 
bone,  bony  cavities  are  olten  formed  as  big  as  the  head  of  a 
new-born  child.  In  cases  of  aneurism,  it  is  more  difficult  for 
the  periosteum  to  live,  or  to  form  those  bony  cavities,  but  when 
such  cavities  are  formed,  they  are  filled  with  blood  like  coffee- 
grounds,  and  constitute  a  most  irregular,  or  as  it  has  been  term- 
ed, anomalous  disease  ;  and  round  the  outside  of  such  bony  ca- 
vities go  the  enlarged  branches  of  the  artery,  which  preserve  the 
limb  notwithstanding  all  this  disorder.  It  is  in  such  cases  that 
we  are  almost  at  a  loss  to  say,  whether  aneurism  or  exostosis 
has  most  share  in  forming  this  fatal  tumour. 

I  shall  illustrate  this  species  of  mixed  aneurism,  by  relating 
a  case  which  was  communicated  to  me  two  years  ago  by  my 
friend  Dr.  Jeffry,  professor  of  anatomy  in  Glasgow,  whose  abi- 
lities and  zeal  are  universally  known.  Dr.  Jeffry  had  the  good- 
ness to  send  me  along  with  the  preparation,  the  following  short 
narrative  of  the  case  : 

41  An  old  woman  of  about  fifty  years  of  age,  was  rode  down 
in  the  streets  by  a  cart,  and  her  arm  broken  in  two  places.  One 
of  those  fractures  was  about  two  inches  above  the  elbow,  the 
other  was  above  the  middle  of  the  arm,  and  the  whole  bone  was 
greatly  shattered  ;  yet  this  poor  creature  had  no  assistance,  no 
surgeon  was  called,  the  arm  remained  unattended  to  for  six 
weeks,  when  Mr.  Parlane,  a  surgeon  in  Glasgow,  visited  her 
and  found  the  arm  greatly  swelled,  so  that  he  could  neither  dis- 
tinctly understand  the  nature  of  the  injury  nor  the  condition  of 
the  bone  ;  it  was  presumed  that  there  was  a  fracture,  and  the 
patient  was  laid  in  a  posture  favourable  to  the  re-union  of  the 
bone." 

u  The  tumour  never  subsided  but  increased,  occupied  the 
whole  arm  from  the  elbow  to  the  top  of  the  shoulder;  pulsation 
was  distinctly  felt  at  the  top  of  the  shoulder,  but  of  such  a  kind 
as  might  proceed  from  some  artery  near  the  surface,  it  was 
judged  to  be  really  so,  the  idea  of  an  aneurism  certainly  had 
never  struck  the  gentleman  who  attended  her,  for  he  opened  the 
tumour  which  was  soft  and  fluctuating,  there  was  no  doubt  of 
its  containing  a  fluid  of  some  kind  or  other  ;  the  lancet  was 
struck  into  it,  but  instead  of  matter,  as  was  expected,  blood 
flowed  in  a  full  stream." 

"This  puncture  healed  up  easily,  the  tumour  which  had 
subsided  when  it  was  thus  imprudently  opened,  soon  filled  up 
again  to  its  full  size,  and  the  hand  and  lore  arm  became  (Ede- 
matous and  cold.  In  this  condition  the  patient  survived  five 
months,  the  tumour  pulsating  manifestly,  epeciallv  in  it*  upper 


70  Of  Aneurism  from  fracture  of  the  Bones. 

part ;  but  how  this  woman  died,  or  after  what  kind  of  suffer- 
ings, is  not  related  in  the  case." 

u  On  opening  the  bodv  after  death,  eight  months  and  more 
having  elapsed  from  the  time  of  the  fracture,  a  profusion  of 
mixed  and  putrid  blood  like  coffee-grounds  was  discharged. 
Two  inches  of  the  lower  part  of  the  bone  retained  its  natural 
form,  all  the  middle  part  of  the  bone  was  destroyed,  the  head 
only  remained  on  the  upper  part  of  the  tumour,  but  with  its 
cancelli  quite  eroded,  nothing  being  left  but  the  mere  6hell. 
Through  the  whole  length  of  the  bone,  the  cancelli  were  comr 
pletelv  dissolved,  and  the  outer  bony  lamina  were  found  adher- 
ing to  the  whole  inner  surface  of  the  sac,  many  pieces  of  the 
bone  were  found  in  the  heart  of  the  tumour,  and  on  the  fore 
part  and  middle  of  the  tumour  was  found  one  piece  of  bone 
two  inches  and  a  half  long  and  nearly  two  broad." 

r*  Although  the  humeral  artery  was  injected,  it  could  not  be 
perceived  from  what  branch  of  it  the  tumour  was  produced." 

We  need  but  to  review  in  the  history  of  this  case  a  few  cir- 
cumstances, in  order  to  understand  the  whole  disease  in  the 
most  unequivocal   manner.      First,  The  sudden  rising  of  the 
tumour,  the  swelling  of  the  whole  arm,  the  fluctuation,  the  pul- 
sation in  the  upper  part  of  the  tumour,  prove,  that  though  the 
chief  part  of  the  tumour  is  found  upon  dissection  to  be  bony, 
yet  aneurism,  and  not  exostosis,  formed  the  basis  of  the  dis- 
ease.    Secondly,  The  striking  of  the  lancet  into  the  tumour 
shows  that  there  was  blood  very  early  ;  the  sudden  filling  up  of 
the  tumour  to  its  full  size,  after  having  been  punctured  with 
the  lancet,  shows  that  the  artery  was  open  at  that  time,  and 
throwing  its  blood  freelv  into  the  sac ;  and  finally,  the  bony  ca- 
vity being  filled  at  the  time  of  death  with  nothing  but  corrupted 
blood,  which  always  after  long  delay  assumes  the  appearance 
of  coffee-grounds,  proves  the  tumour  to  be  merely  an  aneurism  ; 
but  it  is  a  complicated  aneurism  ;  it  is  combined  with  a  frac- 
tured bone  ;  and  the  condition  of  the  periosteum  accounts  for 
the  generation  of  such  extensive  plates  of  bone,  equal  to  a  crani- 
um in  size,  and  something  like  it  in  the  breadth  and  flatness  of 
the  ossifications.     Thirdly,  It  being  proved   that  the  disease 
was  aneurism,  it  is  next  to  be  observed,  that  there  is  not  belong- 
ing to  the  humeral  artery,  as  to  the  femoral,  a  great  profunda, 
or  collateral  branch,  as  large  as  the  trunk  itself  ;  there  are  but 
two  muscular  branches  in  the  arm,  and  those  not  larger  than 
crow  quills  ;  there  is  no  artery,  except  the  trunk  itself,  equal  to 
the  production  of  such  an  aneurism.     The  branches  which  run 
on  the  inner  surface  of  this  tumour,  were  all  singularly  well  in- 
jected, which  shows  that  none  of  thrse  had  am  share  in  pro- 
ducing the  aneurism  ;  and  surely  none  of  them  had  terminated 


Of  popliteal  Aneurism.  71 

in  the  bag;  even  the  force  of  the  injection  had  not  burst  their 
most  delicate  branches;  they  were  lull  of  the  injection,  and 
the  bag  empty.  While  the  entirenessj  of  these  branches  proves 
that  they  had  no  share  in  forming  the  aneurism,  the  enlarge- 
ment of  the  profunda  inferior,  to  such  a  size  as  to  rival  the 
trunk  itself  in  diameter,  is  another  proof  that  the  trunk  was 
wounded  ;  for  nothing  but  the  wound  of  the  trunk  could  thus 
enlarge  the  profunda. 

This  is  one  of  those  cases  in  which,  as  I  have  expressed  my- 
self, one  is  almost  at  a  loss  to  decide,  whether  aneurism  or  ex- 
ostosis has  the  greater  share  in  forming  the  disease.  The  con- 
fusion of  the  case  is  almost  an  apology  for  any  mistake  of  the 
surgeon ;  yet  the  suddenness  of  the  tumour,  the  pulsation,  the 
blood  following  the  lancet,  were  signs  too  conclusive  to  allow 
of  any  doubt.  There  must  have  been  in  a  certain  stage  of  this 
case  such  oedema,  oppression,  coldness  of  the  limb,  and  sup- 
pression of  the  pulse,  as  might  have  intimated  to  the  surgeon 
that  the  change  in  the  state  of  the  circulation  had  taken  phtce, 
on  which  the  fate  of  such  a  limb  depends.  The  patient  living 
with  an  aneurism  certainly  proceeding  from  the  rupture  ot  the 
great  artery;  living  also  under  such  a  complicated  and  oppres- 
sive disorder,  fracture,  exostosis,  and  extravasated  blood,  proves 
to  us  that  there  is  hardly  any  case  in  which  we  need  despair ; 
and  the  enlargement  of  all  the  arteries  in  this  limb,  is  authority 
for  performing  the  operation  for  aneurism,  even  when  the  main 
artery  is  ruptured,  along  with  a  fracture  of  the  bone. 


SECTION    III. 

Peculiarities  of  popliteal  Aneurism. 

In  all  cases  of  neglected  aneurism,  this  destruction  of  the 
soft  parts,  and  caries  of  the  bones,  is  the  last  stage  of  the  dis- 
ease. But  in  popliteal  aneurism,  whether  proceeding  from  spon- 
taneous dilatation  of  the  artery,  or  arising  from  strains,  frac- 
tures or  wounds,  the  danger  is  peculiar;  for  the  aneurism  is  so 
confined  under  the  heads  of  the  gastroenxmii  muscles,  and 
betwixt  the  tendons  of  the  hamstrings,  that  the  resistance  to  its 
extension  is  very  great,  the  destruction  within  is  proportiona- 
bly  rapid,  and  the  disease  is  always  attended  with  severe  pain. 

The  popliteal  artery  passes  between  the  condyles  of  the  thigh- 
bone, and  behind  the  knee-joint,  by  every  motion  of  which  it 

i  Does  not  the  entirenefsof  the  trunk  as  fully  prove  that  the  ancurifm  was  not 
caufed  by  a  wound  of  it  ?— S. 


72  Of  popliteal  Aneurism. 

is  affected.  It  also  lies  under  the  gastrocnjeinii  muscles,  whence 
it  is  endangered  by  every  strain  of  a  limb  which  is  very  pow- 
erful, and  which  supports  the  whole  weight  of  the  body.  A 
man,  for  example,  has  a  fall  from  his  horse,  and  hurts  his  ham, 
or  strains  it  in  mounting  his  horse ;  or  his  limb  falls  in  be- 
twixt the  rounds  of  a  ladder,  and  is  violently  and  suddenly 
bent ;  or  he  receives  a  blow  upon  the  ham,  or  he  is  seized  with 
a  sudden  cramp  in  the  calf  of  his  leg,  and  from  that  moment 
his  pains  and  lameness  begin.  Whether  the  artery  be  merely 
stretched  and  inflamed,  or  whether  it  absolutely  gives  way  un- 
der such  accidents,  is  little  to  the  present  purpose ;  but  thus  it 
is  that  the  disease  begins,  and  is  long  unsuspected  by  the  sur- 
geon, while  the  patient  walks,  or  refrains  from  walking,  by  fits, 
as  the  pain  happens  to  be  more  or  less  violent,  rubbing  the  part 
perhaps  with  camphorated  oil. 

Thus  all  parties  continue  indifferent  to  one  of  the  most  fatal 
diseases.  The  ham  is  straitened,  whence  the  tumour,  even 
from  the  first,  is  of  stony  hardness.  From  this  straitness  it 
loses  very  early  the  marks  of  aneurism,  for  the  pulsation  often 
ceases,  or  is  very  obscure.  The  tumour  (even  in  natural  a- 
neurisms  of  the  ham)  is  not  always  clearly  circumscribed,  nor 
to  be  fairly  traced  to  any  connection  with  the  artery  ;  and  be- 
ing covered,  and  its  pulse  suppressed  by  the  great  thickness  of 
the  muscles  and  skin,  the  nature  of  the  disease  remains  un- 
known. From  the  same  pressure  the  leg  becomes  very  early 
cold  and  (Edematous  ^  for  the  veins,  lymphatics  and  artery,  all 
pass  in  this  straitened  cavity  of  the  ham,  the  pressure  upon  these 
produces  a  general  swelling  of  the  limb,  which  conceals  the  par- 
ticular tumour.  From  the  elevation  of  the  bellies  of  the  gas- 
troensemii  muscles  over  the  tumour,  and  from  the  distention  of 
the  hamstring  muscles,  the  limb  is  thrown  into  severe  and 
painful  cramps  ;  and  from  the  nerve  passing  over  the  tumour, 
(pressed  sometimes  quite  flat)  a  very  distressing  numbness  is 
always  felt,  and  the  lameness  and  pain  are  such  as  the  external 
swelling  cannot  account  for.  All  these  distresses  of  pain,  cramps, 
swelling,  and  general  numbness  of  the  limb,  increasing  every 
dav,  the  patient  sometimes  dies  of  locked-jaw,  fever,  or  long- 
suffering  and  want  of  rest,  the  disease  becoming  fatal  before 
i.hat  period  arrives  in  which  the  tumour  bursts. 

Although  it  is  very  certain  that  aneurism  is  often  unattend- 
ed with  pulsation,  yet  it  is  not  unlikely  that  sometimes  those 
collections  of  blood  which  fill  the  ham,  and  hurt  the  joint,  and 
end  in  caries  of  the  bones,  proceed  from  ruptures  of  the  veins  ; 
for  the  veins,  more  delicate  than  the  arteries,  are  exposed  to 
the  same  violences  as  the  artery,  since  they  accompany  it ;  and 
varices  of  the  internal  veins   are  capable  of  producing  similar 


Natural  progress  of  Aneurisms.  TJ 

effects  with  proper  aneurisms.  The  destruction  of  the  bones 
arises  not  from  the  pulsation  of  aneurism,  nor  from  any  thing 
peculiar  in  the  nature  of  the  arterial  blood,  but  merely  from  the 
injection  of  the  cellular  substance  with  the  blood,  together  with 
the  general  pressure,  and  the  internal  ulceration,  bom  the  pre- 
sence of  a  foreign  body.  Perhaps  the  sudden  rising  of  a  tu- 
mour from  a  strain  of  the  limb,  a  sense  of  laceration  in  the  part, 
the  slow  increase  of  the  tumour,  and  the  total  absence  of  pul- 
sation through  all  its  stages,  may  l>e  esteemed  among  the  si  (ins 
of  a  ruptured  vein.'j" 


SECTION    IV. 

i 
Of  the  Progress  of  Aneurisms,  and  their  Cure. 

IN  the  natural  progress  of  every  aneurism,  there  is  a  certain 
critical  point  to  which,  when  it  arrives,  the  struggle  betwixt  the 
pulsation  and  the  resistance  must  end.  If  the  pulsation  is  to 
prevail,  the  parts  become  thin,  the  tumour  bursts,  and  the  pa- 
tient expires.  If,  on  the  other  hand,  the  resistance  be  such  as 
to  oppress  the  artery,  then  the  pulsation  does  not  all  at  once 
cease,  but  the  collateral  arteries  enlarge,  and  begin  to  carry  off" 
the  blood  from  the  aneurism  at  the  very  moment  it  threatens  to 
burst.  By  this  change  of  circulation,  the  pulsation  of  the  artery 
is  weakened,  so  that  the  swelling,  weight,  and  resistance  of  the 
surrounding  parts,  and  of  the  coagula  formed  within  the  aneur 
rism,  are  able  to  resist  the  stroke  of  the  artery  ;  its  pulsation 
flags,  and  the  collateral  arteries  enlarge;  its  pulsation  at  last 
ceases,  and  there  is  to  be  observed,  betwixt  the  loss  of  one  cir- 
culation and  the  establishment  of  another,  an  interval  ot  coldness 
and  deadness  in  the  limb.  The  circulation  is  thus,  for  some 
time,  upon  the  turn  ;  and  when  this  critical  period  arrives,  the 
limb  is  prepared  for  the  happiest  <  hanges  ;  and  no  sooner  is  the 
circulation  in  the  great  arteries  stopped,  than  that  of  the  col- 
lateral arteries  is  substituted  in  its  place. 

This  enlargement  of  all  the  smaller  arteries  implies  a  condi- 

f  In  one  cafe  the  diforder  was  fairly  traced  to  the  veins.  Mr.  Elfe,  in  his  works 
relates  a  cafe  of  thi>  kind,  in  which  the  limb  was  amputated  on  account  of  the  ca- 
ries  of  the  bone.  Upon  throwing  a  wax  injection  into  'he  arteries,  it  was  not  cx- 
travafated  in  the  tumour,  but  ran  freely  along  the  arteries  to  the  toot.  Upon  ex- 
amining the  gri  at  vein,  a  rupture  was  found  immediately  above  one  ot  the  valves. 

Any  tumour,  lying  in  contact  with  an  artery,  will  receive  a  pulfatory  motion 
from  it ;  therefore,  a  tumour  from  a  ruptured  vein  might  puifate.     I.  the  tumour 
be  fufficiently  loft,  to  enable  you  to  prefs  out  all,  or  even  a  very  large  proportion 
of  its  contents,  it  is  evident  that,  if  it  arile  s  from  a  ruptured  vein  it  will  not  fill  with  * 
'tie  fame  rapidity  as  from  a  divided  artery. — S. 

K 


74  Guattam's  Operation. 

tion  of  an  aneurismal  limb,  which,  though  hitherto  unnoticed, 
is  too  full  of  important  conclusions  to  be  omitted  ;  and  the  con- 
dition of  the  aneurismal  limb  is  still  the  same,  whether  we  per- 
form the  cure  by  tying  the  artery,  or  attempt  it  by  compression, 
or  whether  we  neglect  the  aneurism  till  it  obstructs  the  artery, 
and  obliterates  it  by  its  pressure,  or  bursts  inwardly  among  the 
cellular  substance. 

When  the  celebrated  Guattani  succeeded  in  curing  aneurism 
by  long  confinement,  with  compression  and  firm  bandaging,  he 
believed  that  he  had  repressed  the  aneurism,  and  actually  saved 
the  channel  of  the  blood,  by  preserving  for  it  a  free  course 
through  the  main  artery  of  the  limb.  Were  this  opinion  cor- 
rect, the  tumour  should  yield  at  first,  then  become  flaccid,  then 
its  blood  should  be  altogether  discharged  into  the  artery,  and 
the  artery  should  be  apt,  on  removing  the  bandage,  to  inject 
the  empty  bag  and  fill  it  again  :  in  short,  the  sac  of  the  aneu- 
rism should  be  repressed  as  a  prelude  to  the  cure  of  the  disease. 
Again,  suppose  (by  some  process  of  the  economy,  which  I  can- 
not foresee,  and  which  surely  never  did  happen)  that  this  were 
really  the  succession  of  the  phenomena  in  this  cure,  the  artery, 
after  such  a  cure,  should  carry  its  blood  freely,  the  pulse  should 
be  as  strong  as  ever,  and  whatever  remained  of  the  tumour, 
though  it  were  but  a  thickening  of  the  parts,  should  receive  the 
stroke  of  the  artery,  and  this  residuum  or  remains  of  the  tu- 
mour continuing  to  pulsate  thus,  the  operator  never  could  be 
assured  of  his  cure,  and  would  never  lay  aside  his  compress. 

But  in  truth,  the  last  stage  of  the  process  is  this:  The  arte- 
ry being  for  some  time  opposed  by  the  gradually  increasing 
tension  of  the  parts,  the  blood  is  thrown  upon  the  collateral 
branches ;  the  blood  passing  along  the  collateral  branches,  al- 
lows the  compression  to  be  increased  without  that  intolerable 
sense  of  numbness  and  pain,  which  the  compressions  of  the  first 
week  cause.  At  last  the  compression  is  supported  boldly,  firm- 
ly, unremittingly.  If  the  operator  stop  short  of  this,  the  dis- 
ease returns ;  but  if  he  entirely  compress  the  artery,  the  blood 
forsakes  it,  the  pulsation  stops,  the  tumour  remains  solid  and 
firm,  and  does  not  enlarge,  because  the  blood  no  longer  flows 
into  it,  nor  does  it  even  beat  again,  because  the  artery  which 
lies  under  it  is  obliterated  by  the  pressure.  Thus,  we  per- 
ceive, that  Guattani,  when  he  cured  by  compression,  had  no 
reason  to  continue  his  bandages  for  years,  nor  to  fear  a  return 
of  the  disease.  He  performed,  in  fact,  a  radical  operation  ;  he 
obliterated  the  artery  as  fairly  as  if  he  had  tied  it  with  the  four 
tapes,  which  have  been  so  often  used  in  this  piece  of  surgery. 

A  grave-digger  had  an  aneurism,  which  was  large,  attended 
with  pain,  fever,  a  throbbing  pulse,  and  great  swelling  of  the 


Spontaneous  Cure.  75 

limb,  but  not  particularly  bard  ;  you  rather  seemed  to  feel  in  it 
a  sort  of  fluctuation.  But  the  case  was  well  marked  ;  for  n  in 
the  last  week  of  July  he  had  hurt  his  limb  in  a  very  violent  ef- 
fort; it  was  while  he  strained  very  hard  in  lifting  the  confes- 
sion-desk from  one  part  of  the  church  to  another,  that  he  felt 
something  give  way  in  his  ham,  with  a  sudden  pain,  but  yet 
bearable,  so  that  he  was  able  ior  some  time  to  continue  his  la- 
bours. He  was  ignorant  of  the  nature  of  his  disease,  and  had 
used  only  the  more  harmless  applications,  till  the  time  of  his 
being  laid  in  the  Hospital  of  St.  Peter,  under  Guattani's  care. 

"This  man  was  brought  to  the  hospital  in  the  first  week  of 
August.  For  the  first  eight  days  he  was  bled,  dieted,  confined 
to  bed,  and  reduced  so  that  the  stricture  of  the  bandage  might 
be  safe  and  tolerable.  Then  the  compression  was  begun,  car- 
ried on  step  by  step,  and  occasionally  renewed  ;  but  on  the  first 
week  of  November,  Guattani  found  that  the  pulsation  of  the  tu- 
mour had  entirely  vanished,  and  the  tumour  remained  move- 
able." "  Yet  I  failed  not  (says  he)  to  renew  the  compression, 
and  with  such  happy  success,  that  by  the  middle  of  January 
my  patient  left  the  hospital  perfectly  cured,  excepting  a  halt  in 
his  gate,  and  that  not  remarkable."  M  Two  months  after,  I 
sent  for  him  to  examine  the  parts,  when  I  found  in  the  ham 
nothing  but  a  small  hardness,  about  the  size  and  shape  of  a 
chestnut,  resembling  an  exostosis." 

There  cannot  be  imagined  a  more  correct  history  of  an  arte- 
ry obliterated  by  compression.  The  patient  was  bled,  kept 
upon  very  low  diet,  and  confined  to  bed,  which  relaxed  the 
parts,  and  the  tumour  was  so  compressed,  that  in  the  course  of 
one  month  the  pulsation  disappeared  !  The  pulsation  had  dis- 
appeared, though  the  tumour  remained,  which  shows  thatthere 
was  not  pulsation  enough  in  the  artery  even  to  affect  the  tumour. 
He  next  performed  a  work  of  supererogation,  for  the  artery 
was  obliterated,  the  pulsation  gone,  the  rest  should  have  been 
left  to  nature  ;  but  he  applied  his  compress  and  bandage  again, 
and  in  the  two  succeeding  months  did  no  more  than  stiffen  the 
ham. 

Let  us  next  observe,  whether  we  have  not  the  same  marks 
of  obliteration  of  the  artery,  even  in  those  cases  of  spontane- 
ous cure,  where  the  surgeon  thinks  that  the  canal  of  the  great 
artery  is  still  pervious.  Mr.  Blagden,  surgeon  at  Petworth, 
was  consulted  by  a  man  of  about  fifty  years  of  age,  tall  and 
muscular,  who  had  his  humeral  artery  wounded  in  opening  the 
basilic  vein.  The  blood  flowed  in  great  quantity  ;  and,  per 
saltum,  was  stopped  by  strong  compression.  First,  an  ecchy- 
mosis  extended  itself  generally  from  the  shoulder  to  the  wrist ; 
then  the   aneurismal  tumour  formed,  and  in  six  months  it  had 


76  Hunter9*  Operation. 

increased  to  the  size  of  a  cricket  ball.  The  arm  was  oppress- 
ed, cold,  shrunk,  and,  as  the  patient  expressed  it,  painfully 
lifeless  :  he  was  advised  to  have  the  operation  performed,  hut 
he  first  thought  of  consulting  Mr.  Blagden. 

Mr.  Blagden  found  the  aneurism  of  this  great  size,  hard; 
with  a  strong  pulsation  in  it,  but  the  fore-arm  below  was  told 
and  pulseless.  Now  the  patient  had  assured  Mr.  Blagden  that 
the  tumour  had  been  larger;  that  it  was  subsiding  ;  that  the 
pulse  in  it  was  somewhat  abated  ;  and  Mr.  Blagden  did  not 
scruple  to  advise,  that  he  should  wait  the  issue  ol  these  changes, 
rub  the  arm  with  the  flesh-brush,  and  refrain  from  exertions. 

In  a  few  weeks  the  arm  grew  a  little  warmer  :  in  about  three 
months  he  began  to  be  sensible  of  a  tremulous  pulse  at  the  wrist : 
the  tumour  gradually  diminished,  and  the  strength  of  the  pulse 
at  the  wrist  increased  :  in  eight  or  ten  months  the  tumour  in 
the  bend  of  the  arm  was  reduced  to  the  size  of  a  hazel-nut, 
while  the  pulse  at  the  wrist  was  quite  restored,  and  the  arm  as 
full  and  fleshy,  as  capable  of  as  powerful  exertions,  as  the  sound 
one  ;  but  he  was  desired  to  avoid  such  exertions. 

The  author  concludes  with  this  st  ntence  :  "  It  is  too  evident 
to  admit  of  any  doubt,  that  the  circulation  is  carried  on  in  its 
usual  course  through  the  artery,  and  not  through  the  lateral 
anastomosing  branches  of  it." 

I  am  well  assured,  that  in  this  case  the  blood  passed  only 
through  the  anastomosing  branches  ;  the  profunda  and  ramus 
anastomoticus  were  enlarged,  the  trunk  obliterated,  and  the 
circulation  along  the  fore  part  of  the  arm  gradually  subsided  in 
proportion  as  the  vessels  upon  the  back  part  enlarged. 

As,  however,  spontaneous  cures  are  rarely  to  be  expected, 
and  as  there  are  but  few  cases  in  which  compression  can  be 
used,  I  should,  in  every  instance,  recommend  the  operation 
first  disovered,  or  at  least  introduced  into  practice,  by  Mr. 
Hunter.*  This  operation  is  one  of  the  most  important  im- 
provements in  modern  surgery,  and  one  which  only  a  great 
surgeon  could  invent.  In  this  operation  you  imitate  the  natu- 
ral and  spontaneous  cure  :  the  limb  is  prepared  for  that  change 
which  you  mean  to  complete  by  your  operation  :  the  main  ar- 
tery is  compressed  by  the  aneurism  :  the  collaterals  are  enlarg- 
ing :  nature  has  begun  a  process,  with  which  it  is  dangerous  to 
interfere,  which  you  are  to  complete  :  you  cannot,  with  pru- 
dence, make  an  incision  into  the  diseased  mass:  you  would 
not  choose  to  cut  the  parts  which  are  supplied  with  blood  by 
those  very  inosculations  which  you  wish  to  save.  In  Mr. 
Hunter's  operation,  you  tie  the  artery  far  above  the  aneurism, 
and  thus  avoid  a  part   of  the  artery,  which  is   frequently  dis- 

*  This  operation  is  practicable  in  the  neck  or  extremities  only.     S. 


Effects  of  it.  77 

eased  :  you  stop  the  blood,  and  throw  the  whole  circulation 
upon  the  inosculating  arteries :  you  but  complete  that  process 
which  nature  had  begun,  and  leave  the  absorption  of  the  tu- 
mour to  time. 

You  make  this  small  and  superficial  incision  (hardly  three- 
inches  in  length)  upon  the  tore  part  of  the  thigh,  above  the  part 
of  the  limb  affected  with  aneurism,  and  of  course  you  have  no 
thickness  of  parts  to  cut  through,  except  what  arises  from  the 
general  oedema  of  the  limb.  Your  first  incision  is  through  the 
skin  ;  \  our  next  is  through  the  strong  iascia  ol  the  thigh  ;  you 
encounter  no  inosculating  arteries  ;  you  deprive  the  limb  of  no 
one  blood-vessel,  except  the  great  artery,  which  it  is  at  any  rate 
about  to  lose,  and  which  is  already  much  compressed  ;  you 
make  no  disorder  in  the  limb;  you  touch  no  diseased  part ; 
you  have  no  deep  digging  lor  the  artery  ;  you  have  no  difficul- 
ty, no  uncertainty  in  tying  it ;  you  run  no  risk  of  secondary 
haemorrhagy,  at  least  from  the  articular  arteries  ;  you  make  no 
incisions  among  parts  which  are  choked  with  extravasation, 
where  the  muscles  themselves  seem  hardly  more  alive  than  the 
coagulated  blood  which  they  contain  ;  you  expose  no  joint  to 
ulceration,  nor  any  bones  to  caries.  Far  from  increasing  those 
disorders,  which  are  within  the  injured  part,  you  rather  take 
away  the  cause  of  disorder,  by  preventing  any  further  effusion 
of  blood.  Your  incision  is  small  ;  your  way  to  the  artery  is 
direct ;  you  feel  your  way  by  the  pulse  of  the  artery,  and  are 
assisted  by  \our  knowledge  ot  the  parts  ;  if  you  be  reallv  an 
anatomist,  you  must  perlorm  this  operation  in  a  few  minutes  ; 
if  you  be  not,  and  dare  to  undertake  such  an  operation,  1  know 
of  no  punishment  too  severe  for  such  unprincipled  conduct  ; 
no  human  reproaches  can  touch  a  mind  which  does  not  feel  the 
punishment  within* 

Let  us  now  attend  to  the  effects  of  our  ligature,  not  upon  the 
artery  which  it  intercepts  and  cuts  across,  but  upon  the  tide  of 
blood  which  it  diverts  to  the  other  arteries  of  the  limb.  When 
we  operate  with  a  ligature  on  an  artery,  we  can  mark  the  very 
instant  in  which  it  is  obstructed  :  we  perceive,  alter  a  moment- 
ary coldness  and  deadness  of  the  limb,  a  renewed  action  ol  its 
vessels  and  increased  heat.  We  find  the  limb  cold  when  its 
blood  is  for  a  moment  obstructed  :  we  find  its  heat  rising  far 
above  the  natural  pitch,  while,  as  yet,  there  is  no  pulse  in  the 
great  arteries  of  the  lower  part  of  the  limb  ;  lor  at  this  time  all 
the  smaller  arteries  of  the  limb  are  enlarged  and  acting  very 
powerfully.  The  smaller  arteries  perlorm,  lor  a  certain  term, 
the  office  of  transmuting  blood ;  but  when  one  artery  takes  the 

*  For  particular  directions  for  performing  this  operation,  vid.  Ap.  F. 


78  Natural  progress  of  Aneurism. 

lead,  and  acts  with  such  power  as  to  become  the  direct  trunk 
for  all  the  arteries  of  the  lower  part  of  the  limb,  then  the  gene- 
ral vascular  action  of  the  limb  subsides  ;  the  blood  is  drawn  in- 
to one  or  two  channels ;  the  vessels  in  general  resume  a  natu- 
ral and  quiet  action  ;  and  the  heat,  which  had  risen  6  or  8  de- 
grees above  the  natural  temperature,  falls  to  96. 

Thus,  you  will  observe,  that  the  aneurismal  limb,  which  has 
suffered  the  operation,  and  whose  main  artery  has  been  tied,  is 
not.  deprived  of  circulation,  as  has  been  represented,  nor  cold, 
nor  apt  to  fall  into  direct  gangrene  ;  its  circulation  is  intense  : 
if  disposed  to  gangrene,  it  must  be  to  that  gangrene  which 
arises  from  excessive  action.* 


DISCOURSE  VI. 


ON  WOUNDS  OF  THE  ARTERIES  ;  OF  THE  A- 
NEURISM  WHICH  FORMS  OVER  THE  WOUND- 
ED ARTERY ;  WITH  GENERAL  INSTRUC- 
TIONS AND  RULES  OF  CONDUCT  FOR  THE 
OPERATIONS  ON  SUCH  ANEURISMS. 


SECTION    I. 


Of  the  formation  of  Aneurism  over  a  wounded  Artery. 

W  HEN  a  person  is  wounded  in  any  great  artery,  the  blood 
flows  in  so  full  a  stream,  that  in  a  moment  he  faints,  and  it  is 
then  only  that  the  by-standers  can  command  the  blood  (bv  ga- 
thering up  any  cloths  that  are  at  hand,  and  cramming  them  into 
the  wound  in  a  confused  and  ineffectual  way),  till  at  last  the 

*  There  are  two  cafes  on  record,  in  which  mortification  took  place  in  confe- 
rence of  the  collateral  arteries  not  enlarging  fufikiently  to  carry  on  the  circula 
tion.     Vid.  Appendix  to  Scarpa  on  Aneurifm,  by  Wifhart,  p.  481.     S. 


Formation  of  Aneurism  over  a  wounded  Artery.         79 

surgeon  comes  and  stops  it  altogether.  When  called  in  good 
time  to  such  a  wound,  he  should  clap  the  point  of  his  finger 
upon  the  divided  artery,  or  make  his  assistant  hold  it  while  he 
lays  open  the  wound  more  freely,  obtains  a  distinct  view  of  the 
artery,  and  draws  it  out  from  among  the  cellular  substance  if  it 
be  cut  across,  or  if  it  be  only  punctured,  passes  his  ligatures  un- 
der it  with  the  needle,  the  eyed  silver  probe,  or  any  instrument 
that  is  most  at  hand.  Thus  may  he  prevent  the  aneurism,  the 
extravasation  of  blood,  and  the  destruction  of  the  parts. 

Perhaps  there  are  certain  circumstances,  however,  in  which 
this  would  be  improper  ;  for  example,  if  there  be  a  wound  of 
the  great  arteries  in  the  back  of  the  hip,  in  the  groin,  in  the 
armpit,  we  cannot  command  the  blood  easily  ;  we  are  not  sure 
of  clapping  our  finger  down  upon  the  artery,  at  the  very  point 
where  it  is  wounded  ;  we  are  afraid  lest  the  patient  should  die 
(even  after  we  have  come  to  him),  with  one  single  gush  of  blood ; 
we  therefore  close  the  narrow  wound,  put  its  lips  together,  set- 
tle it  with  a  very  steady  compress  and  bandage,  and  try  to  make 
the  lips  adhere,  and  then  we  have  a  fair  aneurism,  which  we  can 
look  upon  composedly  ;  we  can  reflect  upon  the  course  of  the 
wound,  and  calculate  which  artery  is  most  probably  wounded  ; 
for  besides  the  main  trunk  there  are  other  arteries  in  the  arm- 
pit and  the  thigh,  as  the  arteries  of  the  scapula  or  the  arteria 
profunda,  which,  when  wounded,  will  form  aneurisms  as  large, 
though  not  so  dangerous  as  those  of  the  axillary  or  femoral  arte- 
ries, and  to  be  distinguished  from  them  chiefly  by  the  continu- 
ance of  the  pulsations  in  the  wrist  or  ankle. 

The  advantages  to  be  derived  from  an  aneurismal  bag  being 
formed  over  a  wounded  artery,  either  before  we  are  called,  or 
by  our  own  compresses  forcing  the  wound  to  heal,  are  these. 
That  we  are  not  hurried,  all  at  once  and  unprepared,  into  the 
midst  of  a  bloody  operation ;  that  we  are  somewhat  easy  about 
our  patient's  immediate  safety,  there  being  no  danger  of  imme- 
diate bleeding,  at  least  for  a  few  days  ;  that  we  have  timelv 
warning  of  every  danger,  by  the  changes  on  the  surface  of  the 
tumour,  which  turns  livid,  inflames/  and  gangrenes,  before  it 
bursts.  The  wound  suppurates,  opens,  and  discharges  a  thin 
serum,  before  the  actual  blood  bursts  out,  whence  we  have  time 
to  consult,  to  calculate  which  artery  is  wounded,  and  to  settle 
all  the  steps  of  our  operation  as  deliberately  as  on  any  ordinary 
occasion. 

SECTION    II. 

The  operation  described. 
When  you  are  to  or  eratc  on  any  great  aneurism  high  in  the 


80  Operation  for  Aneurism  described. 

limb,  take  all  the  advantage  that  compression  or  the  tourniquet 
can  give  you  ;  but  do  not  trust  to  them  ;  do  not  allow  yourself 
to  be  confounded  though  the  blood  rush  out  upon  you  ;  be  pre- 
pared to  do  vour  operation  with  an  intrepidity  which  shall  make 
you  independent  of  every  assistance.  First  draw  your  knife 
deliberately  and  fairly  over  the  tumour,  so  as  the  great  livid 
bag  of  the  aneurism,  surrounded  with  its  strong  fascia*,  rises 
into  view.  Next  push  your  lancet  into  the  sac,  and  then  do  all 
that  remains  in  your  operation  with  great  boldness  ;  run  your 
bistoury  upwards  and  downwards  so  as  to  slit  up  the  tumour 
Quickly  ;  plunge  your  hand  suddenly  down  towards  the  bottom  ; 
turn  out  the  great  clots  of  blood  with  your  hand  and  fingers,  till 
having  reached  the  bottom  entirely,  you  begin  to  feel  the  warm 
jet  of  blood,  and  directed  by  that,  clap  your  finger  upon  the 
wounded  point  of  the  artery !  as  it  is  but  a  point,  your  finger 
will  cover  it  fairly,  and  your  feeling  the  beating  of  the  artery 
will  assure  you  that  all  is  safe. 

Now  the  bleeding,  confusion  and  fainting  are  over  in  a  mo- 
ment ;  the  operator  breathes,  and  the  assistants  are  composed ; 
and  all  the  operation  goes  on  easily  and  safely.  The  artery  is 
effectually  commanded  by  this  pressure  with  the  finger  ;  but 
the  first  movement  in  such  an  operation,  viz.  the  act  ot  stopping 
the  blood,  of  getting  at  the  artery,  is  all  boldness,  and  nothing 
of  caution  ;  no  danger  is  to  be  apprehended,  but  that  of  suffer- 
ing your  patient  to  lose  blood. 

Being  now  composed,  you  take  time  to  arrange  every  thing 
for  the  next  step  of  your  operation,  you  feel  the  beating  of  the 
artery  with  the  point  of  your  finger,  perhaps  you  raise  the  point 
of  your  finger  for  a  moment,  to  discover  whether  the  pressure 
of  your  assistants,  at  the  groin  or  clavicle,  commands  the  arte- 
ry:  if  so,*vou  lift  your  finger,  and  examine  round  the  artery  ; 
if  not,  vou  keep  your  finger  steady,  make  the  assistants  clean  the 
sac  round  the  artery  ;  then,  if  the  artery  lies  fair  and  free  in  the 
bottom  of  the  cavity,  you  proceed  to  tie  it ;  but  if  not,  you 
must  dissect  round  the  artery,  until  you  see  it  free  from  other 
parts,  and  have  it  so  insulated  that  you  may  put  your  ligature 
easily  under  it,  unless,  indeed,  the  recollection  of  some  great 
trunk  being  near  the  wounded  artery  (as  of  the  profunda,  when 
you  are  tying  the  femoral  artery),  should  stop  you.  But  yet 
the  nearness  of  any  great  artery  or  nerve  is  an  argument  as 
strong  against  your  diving  with  the  needle  to  catch  the  wound- 
ed artery,  as  against  vour  dissecting  with  the  knife.  Since, 
therefore,  the  dissection  is  done  with  your  eyes  open,  and  you 

*  The  fac  of  futh  an  aneurifm  is  always  formed  by  the  fafcia  covering  the  limbs 
or  mufcles.    S. 


Operation  for  Aneurism  described.  81 

can  see  and  feel  before  the  point  of  your  knife,  rather  dissect, 
or  sometimes  tear  the  artery  naked  with  the  points  of  your  fin- 
gers, tie  its  open  mouth,  it  tut  across,  as  fairly  as  in  an  ampu- 
tated stump  ;  or  if  it  be  punctured  only  with  the  point  of  a  knife 
or  sword,  put  two  ligatures  round  it,  one  above  and  one  below 
the  wound,  and  put  them  neatly  and  fairly  round  the  anew,  and 
then  cut  the  arterv  across  betwixt  the  two. 

But  should  it  happen  that  the  parts  are  so  confused  by  inflam- 
mation, so  disordered  bv  the  driving  of  the  blood  in  old  aneu- 
risms, or  perhaps  so  hurt,  as  to  be  almost  in  a  state  of  gangrene  ; 
if  the  surgeon  cannot  by  any  means  get  a  fair  view  of  the  arte- 
ry, while  his  patient  is  losing  blood,  pouring  from  some  great 
trunk,  then  he  must  strike  his  needle  at  random,  in  order  to 
come  at  his  object  the  nearest  way  ;  and  the  only  satisfaction 
that  he  can  have,  or  the  only  proof  of  his  having  tied  the  artery 
at  all,  will  be  the  sudden  stopping  of  the  blood  when  he  draws 
his  ligature.  In  circumstances  like  these,  the  greatest  surgeons 
(even  Mr.  Pott  himself)  have  been  accused  of  having  missed 
the  arterv  ;  tile  artery  at  all  events,  in  such  a  case,  is  irregularly 
and  insecurely  tied,  the  attendants  that  are  appointed  must  be 
skilful,  and  must  be  interested  ;  both  friends  and  surgeons 
should  watch  over  the  patient's  life  most  faithfully,  for  succes- 
sive bleedings  will  happen  som.times~~tiom  so  slight  an  acci- 
dent as  a  sudden  turn,  or  unwary  motion  in  his  bed  during  the 
night. 

Of  one  thing  I  am  chiefly  afraid,  namely,  that  my  description 
may  seem  overcharged;  that  I  may  appear  to  have  exaggerated 
the  difficulties  of  an  operation  like  this  ;  that  it  may  be  thought 
that  an  accident  requiring  all  these  precautions,  and  this  plun- 
ging down  of  the  hand,  can  hardlv  occur.  Therefore  I  sub- 
mit to  your  consideration  the  following  case,  and  I  dare  say, 
you  will  find  that  it  needs  no  apologv. 

"  A  poor  m  in,  who  was  by  trade  a  leech-catcher,  fell  as  he 
w  is  stepping  out  of  a  boat,  and  the  long  and  pointed  scissors 
which  are  used  in  his  business  being  in  his  pocket,  pierced  his 
hip  exactly  over  the  place  of  the  sciatic  notch,  where  the  great 
iliac  artery  comes  out  from  the  pelvis.  The  .arterv  was  struck 
with  the  point  of  the  scissors,  it  bled  furiously,  the  patient  faint- 
ed ;  and  in  so  narrow  and  deep  a  wound,  the  surgeon,  when  he 
came,  found  little  difficulty  in  stopping  it  up,  and  less  difficulty 
still  in  making  it  heal.  The  outward  wound  was  cured  ;  the 
great  tumour  soon  formed  ;  and  the  man  travelled  up  from  the 
north  country',  where  the  accidt  nt  had  bciallen  him,  and  in  six 
ks  after  arrived  in  our  hospital  here,  with  a  prodigious  tu- 
mour of  the  bip,  his  thigh  rigidly  contracted,  the  ham  bended, 

I. 


82  Operation  for  Aneurism  described. 

the  whole  leg  shrunk,  cold  and  useless,  as  if  it  had  been  an 
aneurism  rather  of  the  artery  on  the  fore  part  of  the  thigh. 

"  The  tumour  was  of  a  prodigious  size,  and  bv  that  very  cir- 
cumstance of  its  being  one  of  the  greatest  aneurisms,  it  had  lost 
all  the  characteristics  of  aneurism.  There  was  no  pulsation,  no 
retrocession  of  the  blood  when  the  tumour  was  pressed  upon  ; 
there  was  nothing  else  peculiar  in  the  tumour  except  this,  that 
the  great  and  sudden  distention  occasioned  great  pain  ;  and 
from  the  continual  pain,  and  lameness,  and  from  having  some 
hopes  of  a  cure,  he  was  ready  to  submit  to  any  thing,  beseeching 
us  to  operate. 

u  There  was  little  doubt  of  this  being  a  great  aneurism,  but 
there  was  a  possibility  of  its  being  a  vast  abscess  ;  and  it  was 
resolved  in  consultation  that  the  patient  should  be  carried  into 
the  operation  room  ;  that  a  small  incision  should  be  made  :  that 
the  skin  being  cut,  the  bag  itself  should  be  just  touched  with  the 
point  of  a  lancet;  if  found  to  contain  matter,  it  should  be  fully 
opened  ;  but  if  blood,  then  it  was  to  be  considered  as  an  aneu- 
rism of  so  particular  a  kind,  as  to  entitle  us  to  call  for  a  full  con- 
sultation. 

"  I  made  an  incision  two  inches  and  a  half  in  length ;  the 
great  fascia  of  the  hip  appeared  blue,  and  very  strong,  forming 
the  coat  of  the  tumour,  and  under  that  were  seen  the  big  fibres 
of  the  great  gluteeus  muscle.  The  knife  was  struck  into  it,  and 
large  clots  of  very  firm  black  blood  rolled  out :  for  such  was 
the  tenseness  of  the  tumour,  that  it  began  to  emit  the  clots  in 
this  way,  the  moment  it  was  punctured.  There  was  one  thing 
further  desirable,  that  before  v/e  put  the  patient  to  bed,  we  should 
understand  the  case  so  far  as  to  be  able  to  report  to  the  consul- 
tation, whether  the  artery  was  absolutely  open,  and  whether  it 
was  the  great  artery  of  the  hip.  I  continued  therefore  (know- 
ing that  the  opening  I  had  made  could  be  covered  with  the  point 
of  the  thumb)  to  pull  out^Jew  more  clots,  till  the  warm  and 
florid  blood  began  to  flo^^  I  then  pushed  in  a  tent-like  com- 
press into  the  small  wound  of  the  tumour  (viz.  of  the  fascia), 
laid  a  broad  compress  over  the  outward  wound,  and  put  the  pa- 
tient to  bed,  with  one  of  the  pupils  holding  the  hand  upon  his 
hip. 

"  This  was  done  at  one  o'clock,  and  at  four  the  consultation 
met,  and  the  operation  was  performed.  And  in  my  notes,  I 
find  two  steps  of  the  operation  chiefly  marked  : — First,  That 
upon  our  opening  the  tumour  fully  with  an  incision  of  eight 
inches  long,  and  turning  out  the  great  clots,  the  blood  was  thrown 
out  with  a  great  whizzing  noise,  and  with  such  impetus,  that  the 
assistants  were  covered  with  it,  and  in  a  moment  twenty  hands 
were  about  the   tumour,   and  the  bag  was  filled  with  sponges. 


Operation  for  Aneurism  described.  83 

and  cloths  of  all  kinds,  which  had  no  better  effect  than  the  cloths 
which,  in  any  accident,  the  iriends  in  great  confusion  wrap  round 
a  wounded  arm  ;  for  though  the  blood  was  no  longer  thrown  in 
a  full  stream,  nor  in  jets,  it  was  seen  rising  through  the  edges 
of  the  incision  ;  it  floated  by  the  sides  of  the  cloths,  which  were 
pressed  down  by  the  hands  of  the  assistants.  But  we  knew 
also  by  a  more  alarming  sign  that  the  olood  continued  to  flow, 
for  the  man,  who  was  at  first  lying  not  fiat,  but  supporting  him- 
self on  his  elbows,  fell  down,  his  arms  fell  lifeless  and  without 
pulse  over  the  side  of  the  table,  his  head  hung  down,  his  face 
was  livid,  he  uttered  two  or  three  heavy  groans,  and  we  believed 
him  dead. 

Secondly,  Seeing,  in  this  critical  moment,  that  if  he  was  to 
be  saved,  it  was  to  be  only  by  a  sudden  stroke,  I  ran  the  bistoury 
upwards  and  downwards,  and  at  once  made  my  incision  two  feet 
in  length  :  I  thrust  my  hand  down  to  the  bottom  ot  the  tumour, 
turned  off  the  great  sponge  which  was  over  the  artery,  felt  the 
warm  jet  of  blood,  put  the  point  of  my  finger  upon  the  mouth 
of  the  artery;  then  I  felt  distinctly  its  pulse,  and  then  only  was 
I  assured  that  the  man  was  still  alive.  The  assistants  laid  aside 
the  edges  of  this  prodigious  sac,  and  sought  out  the  several 
smaller  sponges  which  had  been  thrust  in,  and  the  sac  being  de- 
liberately cleaned,  and  its  edges  held  aside,  I  kept  the  fofe-fin- 
ger  of  my  left  hand  stead)'  upon  the  artery,  passed  one  of  the 
largest  needles  round  under  my  fore-finger,  so  as  to  surround 
the  artery  :  one  of  my  friends  tied  the  ligature,  and  then  upon 
lifting  the  point  of  my  finger,  it  was  distinctly  seen,  that  it  was 
the  posterior*  iliac  artery,  that  the  artery  had  been  cut  fairly 
across,  and  had  bled  with  open  mouth  ;  that  it  was  cut  and  tied 
exactly  where  it  turns  over  the  bone  :  and  although  the  extremi- 
ties were  cold,  the  face  of  a  leaden  colour,  and  the  man  had 
ceased  to  groan,  and  lay  as  dead  ;  though  the  faint  pulsation 
could  not  be  felt  through  the  skin,  in  any  part  of  the  body  ;  we 
saw  the  artery  beating  so  strongly  under  my  finger,  that  we 
were  assured  of  our  patient's  safety  ;  however,  he  was  so  low, 
that  alter  laying  down  the  sides  of  the  sac,  and  putting  bandages 
round  his  body  to  keep  all  firm,  we  were  obliged  to  have  a  bed 
brought  in,  and  having  given  him  some  cordials,  we  left  him 
to  sleep  in  the  great  operation  room,  attended  by  the  pupils 
and  by  nurses.  He  passed  his  urine  and  faeces  involuntarily  tor 
some  days,  and  was  long  in  recovering  his  voice. 

He  was  cured  of  this  great  wound  in  less  than  seven  months, 
although  his  cure  was  protracted  by  the  foul  suppuration  of  such 
a  sac,  and  by  the  exfoliation  of  the  ilium  and  sacrum,  which  spoil- 
ed, not  so  much  from  their  having  been  laid  bare  by  the  last 

*  Called  by  Mr.  Bell  in  his  anatomy  the  gluteal  artery.     S. 


84  Operation  for  Aneurism  described. 

sudden  stroke  of  the  knife,  as  by  the  aneurismal  blood  having 
passed  upon  them  ;  the  exfoliations  were  very  large,  and  the 
sacrum  especially  continued  exfoliating  to  the  very  day  on 
which  the  wound  closed. 

I  do  not  know  whether  this  man  has  recovered  entirely,  for 
he  left  the  house  lame,  from  the  contractions  of  the  hip  and 
ham,  and  walking  by  the  help  of  a  stick ;  but,  however,  he 
thought  himself  fit  to  undertake  his  profession,  and  went  to 
England  with  that  design.* 

SECTION    III. 

Rules  of  Practice. 

In  great  aneurisms,  then,  of  the  arm  or  thigh,  when  the  tour- 
niquet can  be  applied,  do  your  operation  deliberately,  steadily, 
slowly,  but  do  not  needlessly  prolong  your  patient's  suffering. 
Cut  the  skin  nicely,  open  the  sac  freely,  dissect  your  artery 
very  clean,  and  tie  it  clear  of  the  nerve,  and  pass  your  ligature 
with  a  blunt  needle  or  crooked  probe  ;  for  whenever  you  are 
reduced  to  the  necessity  of  using  the  sharp  needles,  your  pa- 
tient is  in  danger.  Tie  your  artery  with  moderate  firmness  ; 
tie  it  in  two  places  (for  on  several  occasions  the  retrograde 
blood  has  flowed  out  even  in  the  time  of  the  operation  ;)  clean 
the  sac  ;  look  now  attentively  to  your  two  ligatures,  and  if  you 
see  the  upper  one  moving  according  to  the  pulsation  of  the  ar- 
tery, all  is  right.  Finally,  if  you  approve  of  my  reasoning, 
cut  the  artery  across  in  the  middle  betwixt  the  ligatures.  When 
the  tourniquet  cannot  be  applied,  do  not  trust  to  compression. 
Your  assistant  may  try  to  compress  the  artery,  but  do  not  lay 
your  account  with  performing  a  cool  deliberate  operation  ;  ex- 
pect rather  a  dash  of  blood  at  the  first  stroke  you  make  into  the 
sac,  and  confusion  and  alarm  of  every  kind.  Compose  your 
mind  for  such  a  scene  ;  bend  up  each  corporal  agent  to  this  at- 
tempt ;  expect  safety  for  your  patient  from  nothing  but  your 
own  daring  operation  ;  be  resolute,  bold,  and  rapid  ;  but  let 
this  boldness  be  the  result  of  serious  deliberation,  and  earnest 
consultation  with  your  friends.  And  in  what  does  this  rapidi- 
ty consist  ?  Is  it  a  dangerous  stroke  that  you  are  to  make  ?  'No 
surely  :  the  rapid  movement  is  merely  slitting  up  suddenly  the 
half  putrid  and  tendinous  sac,  and  turning  out  the  clots  of  blood 
with  your  fingers,  while  the  artery,  nerve,  and  all  the  impor- 
tant parts  lie  safe  at  the  bottom  of  the  tumour.     You  are  to 

*  Dr.  Farquharfon,  who  fucceeded  me  in  the  charge  of  the  hofpital,  has  juft 
informed  me,  of  this  man  having  called  upon  him  after  his  return  from  England, 
walking  ftoutly,  and  in  good  health. 


Of  Wounds  of  superficial  Arteries.  85 

trust  much  to  your  acquaintance  with  the  parts,  therefore  make 
sure  of  your  knowledge  of  the  artery  that  is  actually  wounch  d ; 
return  to  your  books,  drawings,  and  preparations  ;  hold  con- 
sultations with  your  iritnds  ;  lose  no  opportunity  of  making  up 
your  mind  beforehand  ;  the  more  you  reason  upon  the  ease, 
and  revolve  the  possible  dangers,  the  greater  Will  be  your  pros- 
pect of  sustaining  yourself  with  becoming  resolution  in  the 
moment  of  operation. 


DISCOURSE  VII. 
OF  WOUNDS  OF  ARTERIES. 

i 

SECTION    I. 

Preliminary  Observations. 

W  HEN  an  artery,  like  that  of  the  hip  or  thigh,  is  wounded, 
it  lorms  an  uncontrollable  aneurism.  Such  an  artery  drives  eve- 
ry thing  before  it,  forms  a  large  sac,  distends  more  and  more,  till 
it  is  in  danger  of  bursting,  and  if  allowed  to  burst,  proves  fatal. 
But  when  smaller  arteries,  like  those  of  the  lore-arm  or  leg, 
are  wounded  under  the  bellies  of  the  muscles,  the  aneurism  is 
more  irregular,  the  operation  very  difficult,  and  the  dangers 
quite  of  another  kind.  The  blood  is  injected  slowly  among 
the  cellular  substance  and  under  the  muscles  ;  no  sac  is  formed  ; 
the  blood  is  not  collected,  but  diffused ;  the  pulsation  is  slight, 
or  there  is  none  ;  the  limb  is  swelled  and  hard  ;  the  skin  black, 
as  in  a  mortification  ;  the  blood  bursts  out  from  time  to  time. 
It  is  considered  only  as  an  hsertrofrhagy,  while  it  is  in  truth  a 
diffused  aneurism  ;  the  patient,  bv  repeated  loss  of  blood,  is  re- 
duced to  extreme  weakness,  and  the  limb  gorged  with  blood, 
and  with  its  parts  so  insulated  and  disjoined  from  each  other, 
by  the  extravasation,  often  falls  into  gangrene.  These  are  the 
usual  consequences  of  such  a  wound.  If  the  patient  escape,  it 
is  after  long  continued  suppurations,  foul  sinuses,  and  a  great 
destruction  of  the  limb. 


86  Of  Wounds  of  superficial  Arteries. 

There  are  also  .certain  parts  of  the  body  where  the  smallest 
arteries  produce  the  same  consequences.  The  axilla,  lor  ex- 
ample, is  a  very  large  cavity,  filled  with  the  loosest  cellular 
substance,  fit  lor  lodging  the  vessels  and  glands.  1  he  exter- 
nal thoracic  or  pectoral  artery,  which,  if  it  lay  along  the  tem- 
ple, and  were  wounded  there,  could  not  do  the  smallest  harm, 
is  capable  of  forcing  the  cellular  substance  of  the  axilla  ;  it  has 
as  much  effect  on  the  loose  cellular  substance  of  the  axilla,  as  the 
femoral  artery  has  on  the  firm  cellular  substance  of  the  thigh ; 
it  has  often  filled  the  axilla  completely  with  blood,  forming  a 
verv  large  and  dangerous  aneurism.  These  subjects  I  pro- 
pose now  to  explain  to  you. 


SECTION    II. 

Of  Wounds  of  superficial  Arteries. 

The  radial,  ulnar,  and  tibial  arteries,  in  the  lower  parts  of 
the  limbs,  lie  so  superficial,  that  their  bleedings  ought  to  be 
easily  suppressed  ;  awkward  and  imperfect  operations  are  dis- 
astrous only  from  the  successive  hgemorrhagies,  and  not  from 
the  important  size  of  these  arteries. 

The  radial  artery  is  one  of  that  order  and  size  which  cannot 
be  restrained  but  by  the  ligature.  The  superficial  situation  of 
this  artery,  the  nakedness  of  the  bone  on  which  it  lies,  the  great 
swelling  of  those  naked  and  tendinous  parts  a  few  hours  after 
the  artery  is  wounded,  the  difficulty  of  finding  the  artery,  and 
the  cruelty  of  the  operations  which  have  been  performed,  make 
the  case  important,  both  as  a  common  piece  of  surgery,  and  as 
a  general  example  of  this  kind  of  wound. 

The  Radial  Artery,  at  the  place  where  we  feel  the  pulse, 
lies  quite  superficial.  We  even  see  the  beating  of  the  artery 
through  the  skin,  and  when  we  dissect  the  wrist,  or  look  to  a 
preparation,  we  see  noihing  but  the  artery  betwixt  the  skin  and 
the  bone  ;  yet,  when  this  part  is  wounded,  we  seek  in  vain  for 
this  superficial  artery  ;  we  search  for  it  by  cutting  through  a 
most  unexpected  thickness  of  parts  :  this  artery,  which  was 
felt  so  readily  with  the  finger  in  its  natural  condition,  we  can- 
not now  feel  beating,  even  though  the  skin  be  open,  and  the 
wound  deep.  We  observe  the  best  surgeons  at  a  loss  to  find 
the  artery  :  we  find  them  thrusting  down  sponges,  leaving  tour- 
niquets half  screwed  about  the  arm  for  many  weeks  ;  making 
unsuccessful  incisions,  diving  in  vain  with  the  needle,  and,  at 
last,  striking  the  needle  through  the  whole  thickness  of  the  arm, 
so  as  to  intercept  the  artery,  with  a  coarse  ligature  at  the  dis- 


Of  Wounds  of  superficial  Arteries.  87 

tance  of  three  inches  above  the  wound.*  These  difficulties 
never  can  be  explained  by  attending  only  to  the  anatomy  ol  the 
natural  parts  ;  here  the  diseased  and  sound  state  of  the  parts 
must  be  described  together,  and  anatomy  and  surgery  must  go 
closely  hand  in  hand. 

The  artery  of  the  wrist  lies  not  immediately  under  the  skin, 
but  under  a  thick  fascia,  which,  in  its  natural  state,  attracts  but 
little  notice.  The  general  fascia  of  the  fore-arm,  strengthened 
remarkably  at  the  two  condyles  of  the  humerus,  and  farther 
reinforced  by  the  tendinous  expansion  of  the  biceps  muscle  ; 
descends  very  strong  along  the  fore-arm,  enclosing  all  the  flesh  ; 
the  fascia  is  very  thick  at  the  wrist,  where,  though  it  is  a  firm 
and  continuous  web  of  tendon,  its  glistening  fibres  are  distin- 
guished running  across  the  arm,  and  binding  down  the  flexor 
tendons.  Under  this  fascia  the  radial  artery  lies  :  this  fascia 
is  connected  with  the  tendons  below  by  a  loose  and  gliding  cel- 
lular substance  ;  and  it  is  moreover  to  be  remembered,  that  all 
through  the  body  each  artery  has  its  own  peculiar  sheath  of  cel- 
lular substance  !  even  the  smallest  muscular  arteries  have  such 
'^a  sheath.  This  fascia,  which  is  itselt  but  a  firmer  cellular  sub- 
stance, is  surrounded  with  a  looser  tissue  of  cellular  membrane, 
both  on  that  surface  which  lies  upon  the  muscles,  and  on  that 
which  is  connected  with  the  skin. 

No  sooner  is  the  radial  artery  wounded,  than  the  awkward 
attempts  of  the  assistants  prevent  the  blood  bursting  out  freely  ; 
the  cellular  substance  of  the  skin  is  injected  with  blood  ;  and 
the  skin,  long  before  inflammation  could  come  on,  is  inflated, 
as  it  were,  to  a  great  thickness.  The  artery  shrinks  under  its 
fascia ;  the  cellular  substance  of  the  fascia  is  injected  with 
blood  ;  it  rises  over  the  mouth  of  the  wounded  artery  ;  it  is  in- 
jected not  like  the  looser  cellular  substance  of  the  skin.  This 
firmer  cellular  substance  of  the  fascia  is  so  crammed  with  blood, 
and  that  blood  is  so  firmly  coagulated,  that  the  parts  are,  as  it 
were,  baked  together,  and  the  hamorrhagy  is  rather  an  oozing 
of  blood  from  a  substance  resembling  the  Corpus  Cavernosum 
Penis.  The  whole  bottom  of  the  wound  is  a  fine  fleshy  pla- 
centa-like mass ;  and,  after  dissecting  with  the  knife  through 
a  great  thickness  of  parts,  the  artery  is  not  to  be  found  ;  or  only 
by  those  who  are  perfectly  acquainted  both  with  these  changes 
and  with  the  natural  place  of  the  vessel.  This  is  the  confused 
fleshy-like  mass,  into  which  the  surgeon  strikes  his  needle. 
Here  the  blood  is  seen  oozing,  as  through  a  placenta,  at  many 
places,  but  not  one  of  those  bleeding  points  corresponds  with 
the  mouth  of  the  artery  ;  so  that  when  the  surgeon  strikes  his 

•  Mr.  O'Halleran. 


88  Of  Wounds  of  superficial  Arteries. 

needle  at  these  bleeding  points,  he  must  fail.  The  oftener  the 
blood  bursts  out  and  is  suppressed,  the  more  does  the  wrist 
thicken  ;  the  farther  is  the  arterv  removed  from  the  surgeon, 
and  the  more  confused  the  parts  become.  It  is  by  this  extra- 
vasation into  the  cellular  substance  that  the  artery  alwa\S  dis- 
appears, and  the  bleeding  ceases,  before  the  surgeon  is  ready 
to  take  it  up  with  the  needle  :  the  patient  loses  blood  from  day 
to  day  ;  he  becomes  pale,  sickly,  and  exhausted,  till  at  last  the 
blood  hardly  retains  so  much  colour  as  to  tinge  the  sheets.* 

But  another  phenomenon  often  presents  itself,  a  natural  con- 
sequence of  this  state  of  the  parts.  A  person  is  brought  to  us 
a  week  after  the  radial  artery  is  nvounded  ;  it  has  burst  out 
again  and  again  ;  perhaps  the  haemorrhagv  has  been  suppressed 
by  sponges,  by  compression,  or  by  a  rude  stroke  of  the  needle  ; 
but,  upon  undoing  the  dressings,  we  are  surprised  with  the 
appearance  of  a  distinct  aneurism  in  the  bottom  of  an  open 
wound  ;  we  see  a  small  distinct  pulsating  tumour,  regularly 
circumscribed,  throbbing  strongly,  with  thin  and  almost  trans- 
parent coats.  We  are  at  first  at  a  loss  to  imagine  how  such  tu- 
mours are  formed  or  supported.  But  though  the  wound  be 
open,  the  artery  is  not  so  ;  the  cellular  substance  is  partly  in- 
jected with  blood  ;  the  first  effusion  of  blood  is  driven  into  the 
cellular  substance,  mixed  with  it,  and  firmly  coagulated  ;  the 
second  effusion  has  filled  more  of  the  cellular  substance  with 
recent  and  fluid  blood,  and  raised  it  in  the  form  of  an  aneu- 
rism ;  and  this  aneurism  has  for  its  transparent  coat  the  general 
fascia  of  the  wrist ;  but  yet  it  is  so  fairly  circumscribed,  that  one 
would  hardly  doubt  of  its  being  a  dilatation  of  the  artery  itself. 
If  1  do  not  mistake  the  importance  of  this  accident,  it  is  a 
sort  of  duty  to  explain  it  to  you  still  further;  for  though  the 
operation  of  tying  the  radial,  or  ulnar  artery,  does  not  range  in 
the  catalogue  of  important  operations,  along  with  trepan  and 
amputation,  yet,  if  I  be  not  deceived,  it  is  more  difficult  than 
either,  and  certainly  more  frequently  required. 

"  A  shoemaker,  having  been  at  an  annual  dinner  with  some 
young  men  of  his  own  trade,  had  got  merrv,  but  was  not  in- 
toxicated ;  and  some  of  his  companions  walking  home  with 
him,  he  swore  a  hearty  oath  that  they  should  not  pass  his  door 
without  tasting  a  glass.  Accordingly  they  went  in  along  with 
him,  and  as  he  was  reaching  up  to  a  cupboard  for  a  bottle  of 
spirits,  an  unluckv  foot  encountered  his,  and  tripped  him.  He 
fell  forward,  and  a  nail  which  stuck  out  from  the  wall  ran  into 

*  Many  cafes  may  be  found  in  White,  O'Halleran,  Aitken,  &c.  where  a  per- 
fon,  wounded  in  the  radial  artery,  has  bled  lor  three  weeks  or  a  month,  till  the 
blood  was  little  better  than  a  reddilh  ferum.  1  have  taken  up  the  radial  artery 
after  a  pcrfon  has  been  fuffered  to  lofe  blood  ten  or  twelve  times  during  the  courfe 
of  a  fortnight. 


Of  Wounds  of  superficial  Arteries.  80 

the  palm  of  his  hand,  and  wounded  the  Palmar  Artery.  In- 
stantly there  was  a  dreadful  bleeding.  He  fell  down  at  last  in 
a  faint  ;  and  so  unskilfully  was  this  poor  fellow  managed,  that, 
in  the  course  of  a  fortnight,  he  had  been  allowed  to  bleed  no  less 
than  eight  times.  The  blood  burst  out  afresh  on  the  slightest 
motion,  and  at  intervals  of  no  more  than  two  days,  till  ht  was 
reduced  to  extreme  weakness.  He  had  lost  immense  quantities 
of  blood.  It  was  only  by  his  shape  that  I  could  perceive  that 
he  had  been  originally  a  fine  athletic  and  healthy  \oung  man. 

u  I  found  him,  indeed,  in  rude  hands.  The  surgeon  who  had 
attended  him,  and  who  was  to  perform  the  operation,  knew 
nothing  of  the  palmar  arch,  where  it  began,  or  to  which  of  the 
two  arteries  it  belonged,  nor  whether  it  lay  above  or  under  the 
ligament  of  the  palm  ;  and  so  much  was  he  alarmed,  and  so 
ignorant  of  any  but  the  rudest  means  o\  stemming  the  torrent 
of  blood,  that  he  had  a  coarse  bandage  twisted  round  the  hand 
as  firm  as  a  tourniquet  !  The  tourniquet  itself  was  still  round 
the  arm  hard  screwed  ;  and  the  hand,  by  long  continued  pres- 
sure, was  now  black,  not  merely  from  extravasated  blood,  but 
from  actual  gangrene  ;  vesications  appeared  on  it  betwixt  every 
turn  of  the  roller.  The  palm  of  the  hand  was  greatly  heaved 
up  and  swelled,  with  a  puffy  kind  of  swelling.  In  seeking  for 
the  artery,  the  thick  skin  of  the  palm  was  first  cut  through  ;  it 
was  very  thick,  and  exceedingly  crammed  with  blood.  The 
cellular  substance,  belonging  to  the  palmar  aponeurosis  was 
crammed  also  with  blood,  was  fully  two  inches  thick,  quite 
black  ;  it  was  all  one  uniform  mass,  which  cut  like  the  Corpus 
Spongiosum  Penis,  and  no  one  part  was  to  be  distinguished 
from  another. 

"■  The  artery,  with  its  usual  perverseness,  (though  it  had  al- 
most bled  the  man  to  death)  would  not  give  one  drop  of  blood 
during  the  operation.  The  surgeon  unscrewed  the  tourniquet, 
bathed  the  parts  with  warm  water  ;  made  the  patient  swing  his 
hand  most  painfully  ;  made  several  rude  incisions,  but  still 
could  get  no  jet  of  blood  from  the  artery,  nor  any  more  than  a 
general  oozing  from  this  spongy  mass.  Without  fear  of  the 
palmar  nerves,  he  made  many  relentless  and  unsuccessful  at- 
tempts with  the  needle  ;  at  last  he  was  most  unwillingly  forced 
to  make  an  incision  upwards  along  the  artery  :  he  cut  the  skin 
by  the  side  of  the  flexor  ulnaris  muscle,  and  looked  in  vain  for 
the  artery  ;  was  surprised  that  he  could  not  see  an  artery  which 
he  felt  plainly  with  his  finger,  not  knowing  that  the  artery  was 
still  covered  with  its  fascia  :  but  having  at  last  slit  up  the  fascia, 
the  artery  was  forced  out  by  the  tenseness  of  the  fascia  ;  and 
from  its  fullness  it  assumed  a  contorted  form,  and  was  especiallv 
turgid  at  rach  pulsation.     Three  inches  of  the  ulnar  arterv  now 

M 


90  Of  Wounds  of  superficial  Arteries. 

lay  exposed  ;  it  was  seen  running  over  the  Pisiform  bone  into 
this  spongy  mass  in  the  palm ;  the  artery  beat  strongly,  and  was 
seen  serpentine,  and  working  with  a  sort  of  spiral  motion,  and 
a  distinct  pulsation  ;  but  there  was  no  corresponding  jet  of 
blood,  nothing  but  a  general  oozing  in  the  palm. 

"  The  conclusion  of  the  case  is  as  extraordinary  as  all  the 
rest  of  it  ;  the  surgeon  laid  a  ligature  under  this  part  of  the  ar- 
tery, but  would  not  draw  it  ;  he  made  another  desperate  dip 
with  the  needle.  The  lad  was  put  to  bed,  and  the  bleeding 
broke  out  so  furiously  in  the  night-time,  that  had  there  not  been 
a  pupil  watching  to  tie  this  occasional  ligature,  he  surely  must 
have  lost  his  life." 

This  case  explains  to  us  what  confusion  the  continual  driving 
of  the  blood  makes  ;  how  deep  the  artery  lies  in  parts  which 
seem  to  have  little  cellular  substance,  and  how  vain  it  is  to  look 
for  the  artery  in  the  midst  of  such  a  mass  ;  the  artery  will  not 
bleed  till  all  is  quiet  again  ;  and  even  when  it  does  bleed,  it  is 
not  with  a  fair  jet,  nor  with  an  open  mouth.  To  suppress  such 
bleedings  with  a  styptic,  or  a  compress,  seems  to  be  a  lenient, 
but  is,  truly,  a  cruel  practice,  and  not  without  danger.  The 
patient's  constitution,  if  not  his  life,  is  often  endangered  before 
the  surgeon  gets  courage  to  make  the  incision  ;  and  at  every 
return  of  haemorrhagy  the  cellular  substance  is  more  and  more 
injected  ;  the  artery  buried  deeper  ;  the  incision  must  of  course 
be  more  extensive,  and  the  operation  more  difficult. 

The  aneurism  which  I  have  described,  as  formed  under  the 
fascia,  and  protruding  from  the  bottom  of  the  wound,  I  choose 
rather  to  exemplify  from  the  writings  of  another  person,  than 
from  my  own  case-book.  Mr.  Ford,  of  the  Westminster  Hos- 
pital, "  was  called  to  a  butcher  who  had,  about  a  fortnight  be- 
fore, wounded  his  wrist,  by  pushing  his  hand  through  a  pane  of 
glass.  The  wound  was  just  below  the  Carpal  ligament,  over 
the  pisiform  bone.  It  had  bied  several  times  since  the  accident, 
and  the  haemorrhagy  had,  with  difficulty,  been  restrained  by 
bandages  and  common  dressings.  rhere  was  a  pulsating  tu- 
mour covered  with  a  thin  membrane,  where  the  -wound  hud  been' 
received;  the  pulsation  was,  with  difficulty,  checked  by  a  sirong 
compression  on  the  ulnar  artery,  but  returned  again  on  remov- 
ing the  compression. 

"  I  dilated  the  wound  instantly,"  says  Mr.  Ford,  "  towards 
the  palm  of  the  hand,  and  made  an  attempt  to  include  the  ves- 
sel within  a  ligature,  by  means  of  the  common  crooked  needle. 
This  proving  ineffectual,  I  represented  to  the  patient  the  neces- 
sity of  a  farther  dilatation  of  the  wound,  in  order  to  restrain 
the  haemorrhage,  without  injury  to  the  ligaments  and  tendons 
of  the  wrist ;  but,  notwithstanding  the  most  urgent  entreaties, 


Of  Wounds  of  superficial  Arteries.  91 

he  could  not  be  prevailed  on  to  submit  to  any  farther  operation, 
till  the  ensuing  day  :  he  was  therefore  left  with  a  bandage  on 
the  wound,  and  the  tourniquet  applied  on  the  upper  arm,  with 
directions  to  tighten  it,  it  the  hemorrhage  should  return. 

"I  saw  him  ag.iin  on  the  next  day,  in  company  with  Mr. 
Lynn,  surgeon  of  the  Westminster  Hospital,  and  finding  that  the 
bleeding  had  recurred,  it  was  determined  to  prosecute  the  in- 
cision farther,  and  to  secure  the  artery  higher  up  in  the  arm. 

"  I  began  the  incision  where  the  wound  had  been  received, 
earning  it  superficially  over  the  carpal  ligament,  in  the  direc- 
tion of  the  ulnar  artery,  for  six  inches  upwards  in  the  arm. 

M  The  operation  was  done  with  the  utmost  caution,  to  avoid 
wounding  the  tendons  and  muscles,  which  were  carefully  held 
aside  with  our  fingers  as  they  were  exposed  by  dissection. 
This  proceeding  was  of  course  tedious,  in  order  to  ensure  safe- 
ty. The  pulsation  of  the  vessel  could  not  be  felt ;  neither  could 
the  haemorrhagy  be  provoked  by  friction,  by  putting  the  arm 
in  warm  water,  or  by  flannels  applied  hot  to  the  part.  At 
length,  however,  the  artery  was  discovered,  and  a  ligature  car- 
ried round  it,  without  including  any  other  part,  about  an  inch 
and  a  half  above  the  wrist.  Some  time  was  then  employed 
in  endeavouring  to  promote  an  haemorrhagy  from  the  lower 
branch  of  the  artery  ;  but  this  not  taking  place,  the  wound  was 
carefully  cleaned,  united  with  strips  of  sticking-plaster,  and 
rolled  up  with  a  flannel  roller. 

u  The  patient  was  bled,  had  an  opiate  administered,  and  in 
every  respect  was  treated  in  a  most  antiphlogistic  manner.  No 
circumstance  occurred  to  render  it  necessary  to  open  the  wound 
for  six  days  ;  no  swelling,  tension,  inflammation  or  fever,  came 
on.  Now,  it  may  be  remarked,  that  the  circular  ligament  of 
the  wrist,  together  with  the  tendons  and  muscles  contiguous  to 
the  ulna,  had  been  laid  bare,  and  exposed  to  the  air  for  more 
than  three  quarters  of  an  hour,  during  our  search  for  the  artery. 
The  ligature  came  away  on  the  eighth  day,  and  the  wound 
healed  rapidly  by  the  first  intention,  so  that  the  patient  was  per- 
fectly well  on  the  twenty-eighth  of  the  same  month." 

I  know  Mr.  Ford,  and  am  sure  he  will  pardon  any  obser- 
vation that  is  meant  for  the  improvement  of  others.  I  believe 
it  is  needless,  in  any  such  case,  to  cut  downwards  into  the  palm 
of  the  hand,  which  is  usually  so  injected  with  blood,  that  the 
most  dexterous  anatomist,  dissecting  deliberately  on  the  dead 
body,  would  not  find  it  easy  to  show  the  open  mouth  of  an  ar- 
tery; and  it  were  superfluous  to  repeat  to  you  how  improper  it 
is  to  dive  with  a  great  needle  into  the  palm  of  the  hand  :  nor  is 
this  necessary  ;  for  the  palmar  fascia  and  skin  are  so  swelled, 
as  to  prevent  the  return  of  the  blood  from  the  lower  mouth  of 


92  Of  Wounds  of  superficial  Arteries. 

the  artery.  I  never  saw  it  necessary  to  tie  the  lower  end  oi 
the  artery  ;  and  I  think  it  important  to  mention  this,  as  an  ex- 
ception to  the  rule  commonly  laid  down  of  tying  both  ends  of 
it;  it  is  only  the  direct  impetus  of  the  blood  trr  m  the  upper 
part  of  the  arter\  that  bursts  through  this  injected  and  spongy 
mass  ;  it  is  only  the  upper  end  of  the  artery  that  we  need  to  tie. 
Irregular  and  unsuccessful  operations  are  performed  only  from 
not  having  a  very  decided  intention  ot  dissecting  lor  the  artery  ; 
but  it  comes  always  to  this  in  the  end;  and  you  should  resolve, 
the  moment  you  are  called  to  such  a  case,  to  apply  the  tourni- 
quet, to  cut  backwards  along  the  artery  ;  to  dissect  it  clean  ;  to 
tie  it  fairly;  to  disregard  the  bleeding  from  the  lower  end  of 
the  artrry  ;  to  put  a  small  piece  of  sponge  into  the  place  where 
the  blood  oozes  out  from  this  confused  mass,  except  in  those 
very  rare  cases  where  he  sees  a  direct  jet  of  blood  from  the 
lower  end  of  the  artery,  and  then  you  may  use  the  needle  ;  but 
that  rarely  happens,  except  in  very  recent  cases,  and  before  the 
palm  is  much  injected  with  blood.* 

SECTION    IV. 

Of  an  Artery  wounded  by  a  Lancet. 

It  is  to  ignorant  phlebotomists  in  the  country  that  we  are  in- 
debted for  the  various  specimens  of  this  species  of  aneurism. 
They  Use  very  blunt  lancets  ;  and  a  blunt  lancet,  being  pushed 
rudely  onwards,  starts  through  the  skin  at  last,  and  stnkts  deep 
into  the  arm.  The  aneurism  is  generally  produced  by  a  very  large 
and  rude  wound,  like  that  which  the  point  of  a  penknife  would 
make.  •  I  have  seen  many  such  aneurisms,  and  operated  on  se- 
veral. Once,  when  the  operation  was  performed  by  another 
gentlemen,  I  saw  the  artery  so  wounded,  that  it  was  held  to- 
gether merely  by  a  tag;  the  cut  in  it  was   indeed  oblique,  but 

•  Since  the  firft  edition  of  this  work  was  printed,  I  have  met  with  the  following 
cafe,  which  flrongly  proves  how  dangerous-  it  is  to  trufl  to  any  thing  but  a  ligature 
when  an  artery  is  wounded  ;  even  although  it  fhould  be  one  ot  fo  final!  a  lize  a* 
the  palmar  artery  or  a  boy. 

A  lad  of  about  13  years  of  age,  fharpening  a  pen-knife,  had  the  misfortune  to 
thruft  the  point  of  it  into  the  palm  of  his  hand.  The  blood  gufhtd  out  with  fuch 
violence  as  to  prove  that  an  artery  had  been  opened,  which,  from  the  Situation  of 
the  wound  could  be  no  other  than  the  ulnar,  where  it  pafles  down  to  form  the 
palmar  arch.  The  haemorrhage  was  flopped  by  compreffion,  the  wound  healed, 
and  every  thing  appeared  to  be  doing  well  for  ten  days,  when  a  fmall  pulfating 
tumour  was  cbferv'.d  under  the  cicatrix.  Little  notice  was  taken  of  this,  but  thir- 
teen days  after  the  accident,  in  the  middle  of  the  night  fo  violent  a  haemorrhage 
took  place  that  the  boy  bled  almofl  to  death  before  it  could  be  flopped.  The  next 
day  I  faw  him,  and  determined  to  take  up  the  artery,  which  I  accordingly  did 
above  the  wrift,  as  the  molt  convenient  place.  No  return  of  the  bleedingtook 
place,  and  the  boy  did  well. 


Of  Aneurismal  Varix.  93 

so  large  that  it  had  severed  the  artery  almost  entirely  across  :* 
for  thr  arterial  coats  arc,  in  their  nature,  hard,  unyielding,  and 
callous  :f  a  wounded  artery  never  heals  :  a  clot  is  usually  in- 
terposed betwixt  the  lips  ot  the  wound  ;  the  blood  runs  freely 
along  the  canal  of  the  artery,  ready  to  flow  through  the  slit  up- 
on the  slightest  exertion  of  the  arm,  or  slightest  motion  of  the 
clot  ;  and  there  lies  a  considerable  collection  of  blood  betwixt 
the  wound  of  the  artery  and  any  compress  that  we  can  apply. 

section  v. 

Of  aneurismal  Varix, 

The  aneurismal  varix  is  a  disease  produced  after  bleeding 
with  the  lancet,  by  the  close  union  of  the  wound  of  the  artery 
with  the  wound  of  the  vein,  and  the  blood  of  the  artery  rush- 
ing into  the  vein  through  this  side-passage  distends  it.  The 
blood  passes  so  easily  into  the  vein,  that  little  goes  downwards 
along  the  artery  ;  the  arm  below  is  impoverished  of  blood,  and 
is  greatly  weakened  ;  the  dilatation  of  the  vein  increases  al- 
most to  bursting  ;  and  as  the  vein  and  artery,  though  they  run 
parallel,  are  not  in  contact  with  each  other,  but  arc  separated 
by  the  sheet  of  tendon  named  the  Fascia,  the  communication 
betwixt  (he  vein  and  artery  comes  to  be  of  considerable  length  ; 
by  emptying  the  dilated  vein,  and  pinching  with  your  fingers 
and  thumb,  you  can  distinctly  feel  the  communication  betwixt 
them.  \ 

The  artery,  where  it  lies  within  the  fascia,  is  surrounded  with 
a  set  of  small  concomitant  veins,  which,  from  their  encircling  the 
artery,  are  named  Vena?  Comites,  or  Satellites  ;  these  also  ate 
sometimes  struck  with  the  lancet  ;  and,  by  continued  pressure, 

• 

•  Should  theperfon,  who  is  unfortunate  enough  to  punclure  an  artery  in  bleed- 
ing, be  competent,  he  had  better  cut  down,  and  tic  the  veffel  immediately.  For 
it  fomctimes  happens  that  no  diftindit  aneurifmal  is  formed ;  but  the  cellular  fub- 
ftance  ot  the  who.e  arm  becomes  injected,  forming  what  is  called  diffufc  ancu- 
rifm  ;  in  which  cafe,  if  fomething  be  not  fpeedily  done,  gangrene  will  come  on. 
As  this  accident  generally  happens  to  ignorant  perfons,  ancurifm  will  generally 
have  formed  before  a  furgeon  is  confulted.  If  there  be  a  diftindt  aneurifmal  fat, 
he  may  either  operate  in  the  middle  of  the  arm,  tying  the  artery  juft  below  the 
inner  edge  of  the  biceps  mufele,  as  directed  in  popliteal  aneurifm  ;  or  the  fac  may 
be  laid  open,  as  directed  in  the  text.  Whenever  an  artery  is  tied  at  the  place  it 
is  wounded,  which  it  muft  be  in  every  cafe  o.  diffufc  aneurifm,  the  furgeon  had 
better  introduce  a  probe  into  the  tube  of  the  wounded  veflel,  in  order  more  com- 
pletely to  ieparate  it  from  the  contiguous  parts. — S. 

f  Scarpa  mentions  a  remarkable  cafe  of  this,  in  his  work  on  aneurifm,  p.  349.  S. 

i  Aneurifmal    varix  is  likewife  diilinguifhed  by  a  hifling  noife.     Thcfe   cafes 
rarely  require  any  operation.  There  are  iuftances  on  record,  in  which  they  ha  v. 
exilled  for  many  years,   without   producing  any  inconvenience,  the  artery  above 
the  tumour  becoming  fo  much  enlarged,  as  to  carry  a  fufficicnt  quantity  of 
to  compenfate  for  that  which  pafles directly  into  the  vein.    "S- 


94  Mr.  Park's  Case. 

the  artery,  the  internal  vein,  the  fascia,  and  the  external  vein, 
are  all  conglutinated  together  with  a  considerable  degree  of 
confusion  and  thickening  of  parts.  But  however  confused  the 
other  appearances  may  be  in  such  a  case,  this  circumstance  will 
distinctly  mark  the  nature  of  the  disease  ;  that  in  performing 
the  operation  (as  there  are  two  veins  and  one  artery  united  by 
adhesion)  the  surgeon  will  find  two  successive  sacs  of  blood, 
one  under  the  other,  with  a  small  orifice  of  communication  be- 
twixt them.  Perhaps  the  anomalous  case  related  by  Mr.  Park, 
of  Liverpool,  was  of  this  nature. 

The  young  man,  whose  case  Mr.  Park  describes,  had  been 
coarsely  bled,  was  sensible  at  the  time  of  being  struck  too 
deep  in  the  arm,  and  felt  more  than  ordinary  pain.  He  pre- 
sented himself  three  times  successively  at  the  Liverpool  Infirm- 
ary. Even  at  the  first,  this  was  marked  as  an  anomalous  dis- 
ease ;  for  there  wa~  a  complication,  as  if  of  common  aneurism 
with  aneurismal  varix.  There  lay  a  small  hard  circumscribed 
tumour,  no  nigger  than  a  walnut,  immediately  over  the 
wounded  artery,  and  receiving  its  pulsation  ;  and  there  accom- 
panic  d  this  smaller  tumour  a  considerable  aneurismal  dilatation 
of  the  Basilic  vein.  He  called  a  second  time  at  the  Hospital, 
and  sti'il  the  aneurismal  tumour  over  the  artery  held  itself  dis- 
tinct from  the  varicose  dilatation  of  the  vein.  It  was  about  a 
year  after  the  disease  began,  that,  having  used  too  great  free- 
doms with  his  arm,  he  was  brought  into  the  Infirmary  a  third 
time,  with  the  arm  greatly  swelled,  inflamed,  and  partly  sup- 
purated ;  and  the  tumour  having  burst  during  the  night  follow- 
ing his  admission,  there  was  a  necessity  lor  performing  an  ope- 
ratiou,  which,  considering  the  anomalies  of  the  case,  the  late 
hour  at  which  the  operation  was  performed,  and  the  alarming 
loss  of  blood  which  made  it  necessary,  must  have  been  very 
unsatisfactory  to  Mr.  Park.  But  he  delivers  this  interesting 
case  with  singular  modesty  ;  and  though,  in  making  this  ope- 
ration known  to  the  profession,  he  has,  perhaps,  done  no  more 
than  his  duty,  yet  he  has  done  it  in  such  a  manner  as  to  deserve 
our  gratitude.  It  was  remarked  by  Mr.  Park,  that  in  the  time  of 
the  operation,  after  opening  the  first  sac,  he  saw  an  orifice  which 
seemed  to  him  to  be  the  orifice  of  the  artery  ;  but  he  found,  up- 
on introducing  the  probe,  that  it  could  not  pass  upwards  nor 
downwards  farther  than  half  an  inch.  Upon  opening  this  se- 
cond sac,  he  found  at  the  back  of  it  a  second  opening,  a  small, 
round,  circumscribed  orifice,  which  led  into  the  artery.  The 
artery,  thus  discovered,  was  tied  accordingly,  and  the  operation 
finished. 

In  this  case,  one  of  two  things  must  have  happened.  The 
artery,  the  Vena  Comes,  the  fascia,  and  the  outward  vein,  must 
have  all  united  together,   being  massed  and  thickened  bv  in- 


Of  oblique  Wounds  of  Arteries. 


95 


flammation  :  the  ready  communication  of  the  Vena  Comes 
with  the  outward  Vein,  may  have  saved  the  Vena  Comes  irom 
dilatation  ;  and  the  circumstance  of  the  fascia  covering  the  di- 
lated part  of  the  internal  vein,  (and  adhering  to  it)  may  have 
given  it  peculiar  firmness,  and  may  account  for  the  internal  tu- 
mour being  so  small  (it  was  no  bigger  than  a  walnut ;)  and  far- 
ther, the  frequent  valves  in  this  Vena  Comes,  or  internal  vein, 
may  account  for  the  limited  dilatation  of  it,  and  for  the  probe 
not  passing  easily  upwards  or  downwards.  Or,  on  the  other 
hand,  the  artery  may  have  begun  to  form  a  propel  aneurism 
among  the  cellular  substance  ;  the  passage  betwixt  the  tascia 
and  the  vein  may  have  continued  open ;  the  blood  may  have 
made  its  way  from  the  sac  of  this  incipient  aneurism  into  the 
vein  ;  and,  if  so,  the  blood  being  thus  conveyed  away  through 
the  vein,  the  force  would  be  taken  off  lrom  the  proper  aneu- 
rismal  sac,  the  cellular  substance  would  be  condensed  into  the 
form  of  a  regular  bag,  that  bag  would  be  saved  from  further 
distention  by  its  free  communication  with  the  vein,  and  the 
perpetual  circulation  of  fresh  blood,  through  it,  would  prevent 
the  formation  of  clots,  and  would  also  prevent  the  tumour  as- 
suming the  proper  form  of  aneurism. 

Mr.  Park's  Anomalous  Aneurism. 


1.1.  Branches  of  the  Median  Vein. 
1.1.   Branches  of  the  Bafdic  Vein. 

3.3.  The  Brachial  Artery. 

4.4.  The  Vena  Comites  furrounding 
the  Artery. 


5.   Union  of  the  Vena    Comites,  -with  the 
Trunk  of  the  Bafdic  Vein. 

6.  The  ivounded  artery. 

7.  Dilatation  of  the  Vena  Comes. 

8.   Dilatation  of  Med.  Cephal.   Vein* 


SECTION    VI. 

Of  oblique  Wounds  of  Arteries. 

The  point  of  practice,  which  I  have  first  of  all  to  represent 
to  you,  is  the  difficulty  of  finding  the  exact  place  where  an  ar- 
tery has  been  obliquely  wounded  by  the  slanting  stab  of  a  knife 
or  sword,  or  the  course  of  a  ball.     This  difficulty  is  greater 

*  A  cafe  very  fimilar  to  this,  occurred  to  Dr.  Phyfick.  See  Med.  Mufeuni, 
vok  I,  p.  65.    S. 


96  Of  oblique  Wounds  of  Arteries. 

than  it  will  be  easy  for  you  to  imagine ;  for  sometimes  an  ar- 
tery, being  struck  with  the  point  of  a  knife  or  sword,  is  merely 
punctured,  and  not  cut  across.  The  obliquity  of  such  a  wound 
acts  like  a  valve  upon  the  artery  ;  there  is  but  little  blood  pour- 
ed out  under  the  skin,  and  no  remarkable  tumour  is  formed  : 
Now  the  surgeon,  satisfied  from  the  sudden  and  violent  gush 
of  blood  that  an  artery  is  opened,  feels  himself  calkd  upon  to 
look  for  the  blteding  vessel,  and  to  lay  open  the  arm  or  thigh  ; 
but  presuming  too  Tar  upon  his  own  knowledge  of  the  arteries, 
he  makes  a  new  incision  along  the  course  olthe  artery,  neglect- 
ing the  more  easy  and  obvious  xvuy  of  seeking  for  the  wound  in 
the  artery,  by  enlarging  the  natural  wound.*  When,  lor  ex- 
ample, the  artery  being  wounded  from  the  outside,  he  ventures 
to  seek  for  it  by  a  new  incision  from  within  ;  he  gets  to  that 
side  of  the  artery  where  no  wound  is  ;  his  attempts  to  make  it 
bleed,  only  press  the  slit-like  wound  of  the  artery  so  much  the 
more  firmly  down  against  the  flesh  below  ;  he  cannot  see  the 
wound,  nor  even  believe  that  there  is  one  ;  he  tries  to  make  it 
bleed,  but  he  fails  ;  still,  he  sees  the  main  trunk  of  the  artery 
lving  in  the  bottom  of  the  wound,  beating  strongly  under  his 
fing.r,  apparently  entire,  and  he  cannot  yet  believe  that  there 
is  any  wound  in  it.  He  continues  his  work,  but  can  by  no  con- 
trivance force  the  artery  to  bleed  ;  he  can  never  see  where  the 
wound  in  the  great  trunk  is,  nor  be  satisfied  whether  or  not  the 
blood  flows  from  some  smaller  artery  ;  but  no  sooner  does  he 
leave  his  patient,  than  it  bursts  out  furiously,  and  bleeds  from 
time  to  time,  till  the  patient  expires.  It  I  can  produce  one  such 
cas<r,  it  will  be  at  once  a  lesson  and  warning  to  ycu  ;  and  the 
warning  will  be  the  more  impressive,  in  proportion  to  the  re- 
spectable rank  of  the  surgeon,  who  may  have  been  guilty  of 
such  a  mistake. 

A  young  man  of  twenty-five  years  of  age,  in  parrying  a  blow, 
aimed  wTith  a  sharp-pointed  knife,  at  his  breast,  received  it  in 
the  middle  of  his  arm.  The  knife  entered  at  the  outer  edge  of 
the  biceps,  and  touched  the  Brachial  Artery ;  he  staggered  for- 
wards a  few  paces,  and  then,  fainting  with  the  loss  of  blood,  fell 
down.     Unfortunately   there  was  no  one  present  but  a  young 

*  This  rule  has  fome  exceptions  :  thus,  in  thofe  cafes  in  which,  if  the  furgeon 
were  to  attempt  to  follow  the  wound,  he  would  be  in  danger  of  dividing  Come 
important  nerve,  or  have  to  cut  through  a  great  depth  of  mufcle.  Under  fuch 
circumftances,  let  him  difftct  down  to  the  artery  at  the  moll  conveniens  place,  as 
near  the  wounded  part  of  the  veffel  as  poflible,  and  tie  it  firmly  :  Ihould  the  liga- 
ture be  above  the  wound,  of  courfe  every  thing  will  be  fafe ;  if  below  in  con- 
fequence  of  the  obltruclion  to  the  circulation,  the  blood  will  immediately  gufh 
out,  as  happened  in  the  cafe  mentioned  a  little  below  in  the  ttxt,  and  thus  point 
out  the  exact  fituation  of  the  wound.  The  veffel  may  then  be  tied  in  the  man- 
ner directed  in  the  text. 


Of  oblique  Wounds  of  Arteries.  97 

pupil  in  surgery,  so  ignorant  that  he  bled  him  in  the  other  arm, 
and  tied  up  the  wounded  one,  merely  laying  a  compress  upon 
the  wound. 

Till  the  8th  day,  there  was  no  farther  alarm,  when  a  very 
slight  cough  brought  on  a  violent  bleeding  ;  then,  fortunately, 
a  surgeon  was  called,  who  really  understood  the  dangerous  na- 
ture of  the  case,  and  he,  in  his  turn,  called  Mr.  Duschamps, 
upon  whom  the  care  of  the  patient  devolved  ;  he  found  the 
arm  enormously  swelled,  from  the  arm  pit  to  the  elbow,  and 
covered  with  ecchymosis  down  to  the  wrist. 

"  At  nine  in  the  morning,"  says  Mr  Duschamps, "  I  began 
the  operation,  the  patient  being  seated,  and  even  thing  pre- 
pared. But  behold,  when  I  introduced  my  probe  into  the 
wound,  it  passed  so  far  upwards  towards  the  axilla,  that  L  fear- 
ed the  wound  was  very  high,  perhaps  in  the  Axillary  Artery  it- 
self; so  that  instead  of  the  operation  for  aneurism,  I  might  find 
myself  obliged  to  amputate  at  the  shoulder  joint.  I  begged  to 
have  another  surgeon  joined  in  consultation,  and  accordingly 
Mr.  Sabbatier  met  me  in  the  evening  at  five  o'clock.  The  ope- 
ration was  performed  in  the  following  manner  :'' 

Mr.  Duschamps  made  an  incision,  not  by  enlarging  the  na- 
tural wound,  but  by  a  new  cut  along  the  inside  of  the  arm,  in 
the  tract  of  the  humeral  artery,  full  six  inches  long,  extending 
downwards  from  the  tendon  of  the  pectoral  muscle  along  the 
arm  ;  and  by  this  incision  he  penetrated  into  the  aneurismal  bag, 
and  cleansed  it  thoroughlv  of  coagulated  blood.  Mr.  Dus- 
champs and  his  assistants,  then  suspending  the  compression  un- 
der the  clavicle,  hoped  to  see  the  wound,  or  at  least  to  be  di- 
rected to  it  by  the  bleeding  ;  but  though  they  examined  and 
wrought  a  full  quarter  of  an  hour,  and  although  thev  saw  and 
felt  the  main  trunk  of  the  arterv  beating  under  their  fingers,  they 
could  not  by  anv  endeavours  make  it  discharge  one  drop  of 
blood  ;  so  that  one  of  them  ventured  to  say,  he  thought  it  could 
not  be  the  main  arterv  that  was  wounded  ;  while  others  agreed, 
that  nothing  but  a  wound  of  the  main  artery  could  account  for 
the  first  loss  of  blood. 

In  this  state  of  uncertainty,  it  was  resolved  to  lay  an  occa- 
sional ligature  under  the  artery,  which  at  any  time  might  be 
used,  if  necessary,  while  the  arterv* itself  should  be  subdued  by 
compression  alone,  with  agaric  and  dry  lint.  Mr.  Duschamps, 
first,  enlarged  a  little  the  wound  of  the  knife,  and  introduced 
his  finger  into  it,  pushing  it  upwards  towards  the  axilla;  and  by 
this  dissection,  he  applied  his  occasional  ligature  half  an  inch 
higher  than  the  point  of  his  finger. 

Secondly,  He  covered  ail  the  course  of  the  arterv,  within 
the  wound,  with  agaric  and  lint,  secured  by  an  eighteen  tailed 

N 


98  Of  oblique  Wounds  of  Arteries. 

bandage  ;  but  so  slightly  bound  that  it  did  not  suppress  the 
puise. 

At  four  in  the  morning  the  blood  burst  out,  but  it  stopped 
again  of  its  own  accord  ;  it  burst  out  twice  the  next  day,  and 
in  like  manner  stopped  -..gain.  On  the  third  day  it  burst  out 
yet  again  ;  but  the  haemorrhage,  which  came  on  upon  the  fourth 
morning,  was  frightful  indeed;  the  btd  was  soaked  through 
and  through  with  blood,  which,  from  the  toulness  of  the  dress- 
ings, had  contracted  a  horrible  smell.  At  ten  in  the  morning 
I  reached  my  patient,  sa\ s  Mr  Duschamps,  and  undid  the 
bandages.  The  agaric  and  lint  were  left  in  the  incisions,  which 
I  had  made  with  the  knife  ;  the  lint  was  drawn  out  of  the  ori- 
ginal wound  ;  there  was  now  no  bleeding,  and  the  patient  was 
dressed  as  before  ;  but  again,  at  mid-day,  the  blood  burst 
out  with  amazing  force,  and  again  it  was  stopped  by  the  attend- 
ing pupil.  Mr.  Duschamps  now  undid  the  dressings  entirely, 
and  cleaned  the  parts,  hoping  to  see  the  wound  of  the  artery, 
or  at  least  the  jet  of  blood,  but  not  one  drop  flowed.  "  With 
a  patient  so  exhausted,"  says  Mr.  Duschamps,  "  I  durst  no 
longer  trust  to  compression  ;  I  now  resolved  to  draw  the  occa- 
sional ligature,  and  the  instant  that  it  was  drawn,  the  blood  was 
thrown  out  with  force,  proving  very  plainly  that  this  ligature 
was  below  the  place  of  the  wound.  I  applied  instantly  a  se- 
cond ligature  above  the  first  ;  the  blood  was  immediately  stop- 
ped, and  as  immediately  did  the  patient  lose  every  degree  of 
heat  and  ol  feeling  in  the  limb."  At  this  last  operation  of  Mr. 
Duschamps,  his  patient  had  lost  about  three  porringers  of  blood  ; 
half  an  hour  after,  he  fainted  ;  in  a  few  minutes  he  revived  a 
little,  but  a  storm  passing  over  head,  at  this  critical  moment, 
with  some  loud  peals  of  thunder,  affected  him  so  much,  that, 
on  the  third  hour  after  the  operation,  he  expired. 

"Upon  opening  the  body,"  sa\s  Duschamps,  "  we  found 
the  brachial  artery  wounded  from  the  outside  and  from  behind  ; 
the  wound  was  above  the  giving  off  of  the  profunda  humeri, 
small,  punctured,  made  with  the  point  of  the  knife,"  just  under 
the  border  of  the  great  pectoral  muscle  ;  the  occasional  liga- 
ture surrounded  the  artery  immediately  below  the  wound,  and 
that  ligature,  which  had  suppressed  the  bleeding,  was  half  an 
inch  above." 

The  depth  and  obliquity  of  a  wound  may  prevent  the  bleed- 
ing at  first ;  and  it  may  not  be  even  suspected  that  an  artery  is 
wounded,  when  suddenly,  on  the  tenth  or  twelfth  day,  it  bursts 
out  with  such  violence,  as  to  endanger  the  patient's  life.  It  is 
not  .n  gunshot  wounds  alone  that  this  happens,  where  the  ar- 
tery is  not  actually  open  till  the  slough  falls  off  on  the  eighth  or 
tenth  day,  but  in  clean  wounds  with  a  pike  or  bayonet;  for  in 


Of  oblique  Wounds  of  Arterii  u  99 

these  only,  can  the  delay  of  ruemorrhagv  be  attributed  to  the 
obliquity  of  the  wound.  In  the  practice  of  the  older  surgeons, 
we  have  many  examples  oi  this  ;  for  in  their  days  duels  were 
frequent,  and  were  always  fought  with  the  sword,  and  when  a 
gentleman  was  wounded  in  the  sword-arm,  it  often  happened, 
that  although  the  sword  had  run  obliquely  along  from  the  wrist 
to  the  elbow,  and  wounded  the  brachial  artery  at  the  bend  of 
the  arm,  no  bleeding  appeared  outwardly,  the  first  issue  of 
blood  was  so  resisted  bv  the  cellular  substance,  that  it  soon  co- 
agulated, and  filled  up  the  narrow  wound,  assisted  by  the  in- 
flammation and  swelling  of  the  parts.  A  firm  coagulum  was 
formed,  and  it  was  only  on  the  tenth  or  twelliti  day  when  the 
suppuration  was  free,  and  the  clot  began  to  separate,  that  the 
blood  burst  out.  Le  Dran's  Forty-eighth  Observation,  con- 
tains the  case  of  a  gentleman  in  the  r<  giment  ol  Noailles,  who 
was  thus  wounded  with  a  rapier  in  the  sword-arm  ;  the  slight 
bleeding  was  stopped  with  small  dossils  of  lint,  and  the  next  day 
his  hand  and  fore-arm  were  in  good  condition.  Le  Dran,  in  ex- 
amining them,  tound  no  symptoms  ot  a  mounded  artery,  there 
was  a  little  ecchvmosis  towards  the  elbow,  and  a  moderate 
swelling  of  the  whole  arm.  The  dossils  were  at  last  withdrawn, 
the  cure  went  on  well,  the  pus  was  formed,  the  arm  was  not 
swelled,  no  symptoms  of  a  wounded  artery  appeared  till  on  the 
seventh  day  in  the  afternoon.  Being  pressed  to  go  backward, 
he  went  behind  his  tent  with  his  arm  in  a  sling,  and  having,  in 
adjusting  his  clothes,  either  straightened  or  twisted  his  arm,  a 
considerable  haemorrhagy  appeared  suddenly.  When  the  con- 
sultation met  next  day,  it  was  plainly  seen  that  the  artery  was 
open,  the  bloody  tumour  now  extended  from  the  elbow  to  the 
arm-pit  ;  Mr.  Le  Dran  advised  the  opening  of  the  tumour,  or 
the  amputation  of  the  arm  :  his  advice  was  neglected  ;  the  army 
made  a  movement  ;  this  gentleman  was  sent  to  Namure  ;  the 
haemorrhagies  returned;  the  surgeon  was  long  in  resolving  on 
amputating  the  arm,  and  when  he  did  at  last  perform  it,  the 
gentleman  was  so  far  exhausted  by  successive  hemorrhagies, 
that  he  died. 

This  artery  was  found,  upon  dissection,  to  be  wounded  above 
the  condyle,  and  a  hard  clot  of  blood,  which  pressed  it  down 
against  the  bone,  prevented  the  bleeding. 

Thus  it  often  happens,  through  mismanagement,  that  the 
swelling,  the  hamiorrhagies,  the  gangrene,  suddenly  terminate 
in  death  ;  but  in  such  wounds,  the  case  is  olten  protracted  to  a 
greater  length,  displaying,  as  it  were  in  detail,  all  the  dangers 
of  an  oblique  wound. 

A  ball,  we  shall  suppose,  passes  along  the  fore-arm,  rakes 
along  the  two  bones,  wounds  the  radial  or  ulnar  artery  in  the 


100  Of  oblique  Wounds  of  Arteries. 

bottom  of  a  deep  and  narrow  wound,  and  then  passes  beyond 
the  elbow,  making  an  opening  too  small  to  let  out  ihe  blood  ; 
or,  we  shall  suppose  the  oblique  sta'o  of  a  knife,  sword  or  bayo- 
net, touches  an  artery,  lying  thus  in  the  heart  of  the  tore-arm, 
under  all  the  muscles,  and  close  upon  the  bone  ;  then  the  fol- 
lowing consequences  ensue.  The  proluse  bleeding,  at  first, 
proves  that  some  artery  is  wounded  ;  the  direction  ot  the 
wound  ascertains  that  it  is  the  radial  or  ulnar  artery  ;  the  stop- 
ping of  the  outward  bleeding  causes  an  internal  aneurism,  dif- 
ferent from  the  greater  aneurisms  of  the  arm  or  thigh,  as  it 
lies  not  under  a  fascia,  forming  a  fair  circumscribed  aneuris- 
mal  bag,  but  under  the  bellies  of  all  the  muscles,  which  are  se- 
parated from  the  bones,  by  a  very  irregular  and  a  very  danger- 
ous collection  of  blood.  The  outward  bleeding  is  soon  stopped 
by  compresses  and  a  bandage  ;  the  friends  are  less  alarmed, 
seeing  nothing  but  a  narrow  slanting  wound  ;  but  when  the 
next  morning  they  see  the  arm  black  with  the  injected  blood, 
and  swelled  to  an  enormous  degree,  their  fear  is  like  their  in- 
difference before,  quite  ignorant,  and  beyond  the  true  measure; 
they  believe  this  to  be  an  absolute  gangrene,  and  that  the  pa- 
tient is  lost  ;  while  the  surgeon  sees  in  this  blackness,  not  the 
signs  of  gangrene,  but  the  marks  of  a  wounded  artery,  and 
foresees  a  difficult  and  tedious  operation  of  seeking  it  out. 

But  if  again  the  surgeon  have  not  the  skill  to  perceive  all  the 
dangers  ot  the  case,  the  apparent  gangrene  is  soon  changed  in- 
to a  real  one ;  the  limb  becomes  cold,  benumbed,  and  has  a 
livid  redness  upon  its  surface  ;  the  skin  without  runs  into  a  low 
inflammation  ;  the  blood  within  increasing  every  day  in  quan- 
tity, corrupts  and  bursts  out ;  and  thus,  as  I  have  hinted  be- 
fore, it  is  not  merely  by  the  wound  of  its  great  artery,  and  by 
losing  the  great  trunk  that  nourished  it,  that  a  limb  is  lost ; 
but  in  a  case  like  this,  it  is  lost  by  the  deep  driving  of  the  blood 
among  the  flesh  and  bones.  Either  the  outward  bleeding  is 
allowed,  and  the  patient  is  in  danger  of  immediate  death,  or 
the  blood  is  confined,  and  the  bleeding  goes  on  within  :  so  that 
every  time  the  artery  bursts  out,  the  limb  is  injected  anew,  as 
it  were,  by  the  arteries.  The  matter  is  bloody,  fetid,  corrupt ; 
it  prevents  the  re- union  of  the  bones  (if  any  bones  be  broken  ;) 
it  makes  foul  suppurations,  and  extensive  and  fetid  sores  ;  and 
each  new  suppuration  is  succeeded  by  a  dissolution  of  those 
clots  which  had  for  a  time  stopped  up  the  artery,  so  that  again 
the  blood  bursts  out ;  till  at  length,  after  many  months  of  suffer- 
ing, the  patient  is  forced  to  part  with  that  limb  which  he  has 
undergone  so  many  dangers  to  preserve.  The  extensive  si- 
nuses, and  foul  sores,  the  disorder  of  the  joints,  and  the  total 
caries  of  the  bones,  make  every  such  case  incurable  j  there  is, 


Of  Wounds  of  the  thoracic  Artery.  101 

even  from  the  very  first  moment,  no  other  alternative  for  the 
surgeon,  than  either  to  perform  immediately  a  bold  decisive 
operation,  or  to  resolve  at  once  (not  keeping  the  patient  in  this 
lingering  and  cruel  condition)  to  cut  off  the  limb.  To  the  pa- 
tient himseli,  the  question  mav  be  honestly  proposed  in  these 
terms  :  "  Will  you  have  this  tedious,  but  necessary  operation, 
of  tying  the  artery,  regularly  periormed  ?  Or  will  you,  to  shun 
a  present  pain,  linger  lor  months  in  this  miserable  condition, 
consenting  at  last  to  lose  the  limb,  when  it  is  perhaps  too  late 
to  save  your  constitution,  or  even  \our  lite  !" 

The  thoracic  artery,  though  small  and  apparently  unimpor- 
tant, produces  otten  the  most  distressing  consequences  when 
wounded,  and  requires  a  bold  operation.  This  arises  from  the 
looseness  of  the  cellular  substance,  which  surrounds  the  git  at 
vessels  and  nerves  in  the  axilla  ;  and  such  is  the  power  ol  this 
long  and  slender  alter)  over  the  cellular  substance,  that  it  drives 
its  blood  freely  under  the  pectoral  muscle.  The  aneurism 
which  it  forms,  is  as  large  sometimes  as  that  of  the  thigh.  It 
often  happens,  after  a  wound  of  the  thoracic  or  external  mam- 
mary artery,  that  the  whole  side  is  blackened  with  the  suffusion 
of  blood  ;  the  great  cavity  of  the  axilla  itself  is  filled  with  blood, 
(and  it  is  capable  of  containing  a  great  quantity)  the  back  and 
breast  are  black  with  the  ecch)  mosis.  The  appearance  is  so 
formidable  that  the  surgeon  suspects  some  mortal  wound  ;  the 
side  is  so  loaded  with  blood  that  the  patient  is  oppressed,  and 
he  labours  so  in  his  breathing,  that  we  should  believe  him 
wounded  in  the  thorax,  but  that  there  is  no  cough,  nor  blood 
coming  up  from  the  lungs,  nor  emphysema  from  air  issuing 
by  the  wound.  From  the  size  of  the  aneurism  in  the  axilla, 
one  would,  on  the  other  hand,  be  apt  to  believe  the  axillary 
artery  itself  wounded,  but  that  the  pulse  at  the  wrist  continues 
firm.  When  the  axilla  is  thus  filled  with  extravasation,  and 
the  back  and  breast  blackened  with  ecchvmosis,  a  gangrene  of 
the  skin  must  sooner  or  later  ensue  ;  the  discharged  blood  will 
become  foul  and  very  fetid  ;  the  destruction  ol  cellular  sub- 
stance, and  the  irregular  abscesses,  must  extend  far  and  wide  ; 
the  disorder  will  be  several  months  in  being  cured  ;  it  arises 
from  ignorant  surgeons  thrusting  their  stopples  of  lint  into  that 
wound,  which  is  very  distant  from  the  place  where  the  wound- 
ed artery  lies,  which  of  course  continues  to  bleed  within. 

This  must  be  prevented.  It  would  no  doubt  be  very  wrong 
to  cut  up  the  axilla,  or  touch  the  pectoral  muscle  in  pursuit  of 
every  trivial  artery  that  may  be  wounded  on  the  tore  part  of  the 
breast;  nor  would  it  be  sensible  always  r.o  make  incisions  when 
the  long  pectoral  artery  itself  is  wounded;  for  often  the  tho- 
racic arteries,  when  wounded  with  swords  or  musket  shot,  bleed 


102  Of  Wounds  of  the  thoracic  Artery. 

very  smartly,  and  yet  stop  of  their  own  accord,  upon  applying 
merely  a  piece  of  lint  to  the  wound.  Indeed  it  is  not  on  ac- 
count of  the  actual  wound  of  the  artery  that  we  perform  any 
operation,  but  to  prevent  tht  destruction  of  the  cellular  sub- 
stance and  the  diffusion  of  the  blood  ;  therefore,  when  )  ou  find 
that  applying  a  piece  of  lint  with  slight  compression  stops  the 
bleeding,  without  any  appearance  ot  extravasation,  you  remain 
satisfied.  But  if  you  be  called  to  your  patient  a  lew  hours  af- 
ter the  first  dressing,  on  account  of  an  incipient  swelling  and 
slight  oppression  of  the  breast,  and  find  that  the  extravasation 
among  the  loose  cellular  substance  in  the  armpit  is  begun,  you 
must  undo  your  bandages,  withdraw  your  bit  oi  lint,  which  is 
merely  a  stopple  confining  the  blood,  dilate  the  wound,  put  in 
your  finger  and  advance  it  till  you  feel  the  jet  of  warm  blood  ; 
hook  out  the  clots  which  lie  over  the  mouth  of  the  artery,  and 
lay  your  compress  directly  upon  it.  Then  pile  compresses 
over  it  on  the  outside,  and  apply  your  roller;  for  it  is  seldom 
necessary  to  cut  the  wound  entirely  up,  or  to  use  the  needle  in 
wounds  of  the  thoracic  artery. 


DISCOURSE  VIII. 


OF  THE  ANEURISM  FROM  ANASTOMOSIS. 


JL  HAT  kind  of  aneurism  which  I  venture  to  name  Aneurism 
from  Anastomosis,  resembles  those  bloody  tumours  which  ap- 
pear in  new-born  children,  occupying  chiefly  the  lips,  cheeks, 
«yelids,  or  hairy  scalp,  and  which  grow  in  process  of  time  to  an 
important  size,  bursting  at  last,  and  bleeding  furiously,  so  as  to 

oblige  us  to  cut  them  out. 

The  disease  which  I  am  now  about  to  describe  arises,  not  on- 
ly from  such  natural  deformity,  but  also  from  various  and  hid- 
den causes  :  it  often  begins  in  adults,  increasing  from  a  trivial 


Of  the  Aneurism  from  Anastomosis.  103 

pimple-like  speck,  to  a  formidable  disease.  This  aneurism  con- 
sists in  a  mutual  enlargemt  nt  ot  the  smaller  arteries  and  veins. 
I  have  reason  to  believe  that  it  sometimes  originates  from  so 
slight  a  cause  as  a  tight  hat  or  a  trilling  bruise  ;  it  frequently 
begins  in  adults,  in  pure,  hale,  and  sound  skin,  where  no  spot, 
nor  mark,  nor  tendency  to  disease,  had  ever  been  observed. 
The  marks  which  children  are  born  with  are  often  superficial 
stain-like  spots,  which  never  change,  except  that  their  colour 
becomes  occasionally  deeper.  But  sometimes  those  spots  are 
also  defects  in  the  substance  of  the  skin,  they  are  a  species  of 
aneurism,  or  they  create  a  tendency  to  this  disease  ;  and  from 
almost  imperceptible  stain-like  spots,  not  elevated  above  the 
surface  of  the  skin,  they  grow  to  dangerous  bloody  tumours, 
which  require  extirpation. 

In  both  diseases,  viz.  of  connate  aneurisms  appearing,  when 
the  child  is  born,  in  the  form  ot  a  small  livid  tubercle,  and  of 
those  forming  spontaneously  or  arising  from  a  blow,  the  process 
of  their  growth  and  increase  is  the  same.  When  a  set  of  cuta- 
neous vessels  first  enter  into  this  diseased  action,  a  few  of  the 
extreme  arteries  in  the  skin  itselt  are  originally  in  fault,  and 
commence  an  increased  action,  which  draws  the  arteries  of  all 
the  adjoining  parts  into  sympathy  with  them  ;  the  arteries  be- 
hind them  convey  more  blood  and  push  it  on  rapidly  ;  these 
larger  arteries  begin  to  feed  the  disease,  while  the  central  group 
thus  supported  by  the  arteries  behind,  acts  powerfully,  the  tu- 
mour begins  its  pulsations,  and,  like  a  punctum  saliens,  forms 
vessels  as  it  were,  bv  enlarging  those  small  branches  which  were 
not  Visible  before.  The  little  arteries  work  powerfully  and  are 
dilated,  the  corresponding  veins  are  proportionably  enlarged,  the 
number  and  activity  of  those  arteries  and  veins  are  slowly  in- 
creased. This  increased  circulation  solicits  more  blood  towards 
the  tumour  ;  and  while  the  central  branches  impel  their  blood 
with  greater  rapidity,  the  trunks  they  come  from,  follow  up  that 
action  and  work  so  as  to  keep  them  full. 

In  women,  the  phenomena  of  these  tumours  are  very  re- 
markable ;  the  ha^morrhagy  from  them  usurps  the  place  of  men- 
struation, the  action  ot  their  vessels  is  as  regularlv  periodical  as 
that  of  the  arteries  of  the  womb.  The  state  of  menstruation  is 
a  state  of  general  excitement,  and  the  particular  action  may  be 
turned  off  towards  any  set  of  vessels,  as  those  of  the  stomach, 
nostrils,  or  lungs.  The  excitement  of  menstruation  affects  the 
breasts,  it  is  felt  through  the  whole  s\stem,  its  effect  on  every 
tumour  is  remarkabk,  and  I  am  daily  provoked  ac  seeing  can- 
cers, even  of  the  breast,  (which  is  always  peculiarly  affected),  and 
other  tumours  which  actually  rise  and  tail  with  each  menstrua- 
tion, extirpated  without  the  smallest  regard  to  the  menstrual  pc- 


104-  Of  the  Aneurism  from  Anastomosis. 

riod,  though  the  change  at  such  a  time  upon  every  tumour  is- 
such  as  the  most  ignorant  observer  might  remark.  The  disease 
which  I  am  now  explaining,  this  aneurism  from  anastomosis, 
consists  in  the  increased  actios  of  certain  arteries ;  and  the  men- 
strual excitement,  and  the  local  action  coinciding,  cause  periodi- 
cal pulsations,  periodical  enlargements  of  the  tumour,  periodi- 
cal haemorrhages,  and  a  bursting  of  the  tumour  at  each  menstru- 
ation, which  alternations  I  have  known  continue  for  mam  vtars. 

Having  endeavoured  to  settle  the  character  of  this  singular 
species  o!  aneurism,  I  shall  proceed  to  relate,  in  the  first  place, 
a  pure  unc  ncumbered  case. 

Mr.  R — n,  a  young  gentleman  of  about  twenty-five  vears  of 
age,    had   an   aneurismal  tumour  upon  his  forehead,  which  had 
be-  n  growing  for  seven  years.      It  began  with  a  small   spot  like 
a  pimple,  of  the  size  of  a  pea,  and  was,  when  he  consulted  me, 
of  the  size  of  an  egg;  there  passed  along  the  centre  of  the  tu- 
mour the  scar  of  an  operation  which  had  been  performed  about 
a  year  before.       Nothing  could  be  more  singular  than  the  cir- 
cumscribed form,  strong  pulsation,  and  various  peculiarities  of 
this  aneurism.      Nearly  seven  years  before,  he  had  first  observ- 
ed a  small  pimple  like  tubercle  rise  on  his  forehead  (which  had 
hitherto  been  smooth  and  sound),  which  was  seated  close  upon 
the  eyebrow,  and  was  so  small  and  so  little  troublesome,  that  he 
believed  it  to  be  a  pimple  merely,  ascribed  it  to  the  tightness  of 
his  hat,  and  disregarded  it  for  some  time.      When  he  consulted 
a  physician   of  very  excellent  abilities,  Dr.  Cleghorn  of  Glas- 
gow, that  gentleman  ordered  gentle  physic,  and  other  trivial  pre- 
scriptions, in  perfect  confidence  that  it  would  disappear;  for  at 
this  time  it  was  of  the  same   colour  with  the  rest  of  the  skin, 
had  no  character  of  aneurism,  and  was  so  little  troublesome, 
that  it  was  for  a  long  while  after  entirely  disregarded.       But 
when  it  had  attained  to  the  size  of  a  sparrow's  egg,  he  thought 
he  felt  pulsation   in   it    at  times,  he  began  to  be  alarmed  ;  and 
when  at  last  h^  resolved  to  consult  a  surgeon,  the  pulsation  was 
manifest,  the  surgeon  recognized  it  as  an  aneurism,  and  advised 
that  it  should  be  cut  out,  but  not  with  that  earnestness  which  is 
necessary  to  persuade   a  patient,  who  seldom  has  at  first  a  seri- 
ous impression  oi  the  nature  or  consequences  of  such  a  disease. 
Mr.  R — n  advised,  or  rather  talked,  with  others,  but   in   so 
careless  a  wav,  that  he  began  to  be  himself  indifferent  about  the 
tumour,  was  easily  prevailed  upon  to  believe  that  if  it  increased 
at  all,  it  must  be  very  slowly;  this  little  tumour  seemed  at  first 
to  have  arisen  merely  from  a  tight  hat,  and  he  was  easily  per- 
suaded to  hope  that  it  would  go  away. 

One  gentleman  directed  him  to  try  compression,  and  accord- 
ingly, a  plate  of  lead  was  bound  firmly  down  upon  the  tumour  ; 


Of  the  Aneurism  from  Anastomosis.  105 

he  suffered  the  pain  of  this  pressure  with  great  constancy  for 
some  days,  and  for  several  weeks  he  continued  a  less  painful 
degree  ol  pressure  ;  but  finding  the  aneurism  beating  more  pow- 
erfully, foreseeing  no  good  effect,  and  irritated  with  the -con- 
stant and  ineffectual  trouble  ol  supporting  the  pressure,  he 
threw  away  the  bandage,  and  let  the  aneurism  grow  as  it  pleas- 
ed. This  was  about  seven  years  ago  ;  during  five  years  bad 
his  tumour  continued  to  grow,  when  the  nature  of  it  being  no 
longer  equivocal,  and  the  consequence  ol  allowing  it  to  mere  ise, 
much  to  be  feared,  it  was  resolved  to  perform  the  operation. 
There  is  every  apologv  for  the  theory  which  the  surgeon  had 
formed  of  this  tumour,  for  its  form  was  very  singular.  It  was 
seated  immediately  over  the  eyebrow,  and  was  about  the  size  of 
a  small  egg  ;  it  lay  exactly  in  the  course  of  the  frontal  artery. 
The  small  orbitary  artery  was  found  entering  into  the  lower  end 
of  this  oval  tumour,  while  a  branch  of  the  temporal  artery,  re- 
markablv  enlarged  and  tortuous,  went  curling  along  the  temple 
and  passed  also  into  the  upper  end  of  the  tumour.  No  other 
vessels,  neither  arteries  nor  veins,  could  be  traced  to  it,  but 
these  two  arteries,  and  the  intermediate  tumour  beat  in  con- 
cert ;  the  arteries  beat  much  more  powerfully  than  in  their  na- 
tural state,  and  the  tumour  had  a  very  powerful  throbbing. 
This  tumour,  which  became  turgid  whenever  the  pulses  beat 
strong,  seemed  to  be  merely  an  enlargement  ol  the  frontal  arte- 
rv,  fvid.  fig.  l.  p.  108.)  and  under  this  apprehension  was  the 
operation  arranged  as  follows  :  The  surgeon  first  made  an  inci- 
sion in  the  lower  part  of  the  tumour,  and  passed  a  ligature  un- 
der the  orbitary  or  frontal  artery  ;  but  when  he  had  tied  this  ar- 
tery the  pulse  of  the  aneurism  was  nothing  abated.  He  next 
made  an  incision  along  the  temporal  branch,  where  it  ran  into 
the  upper  part  of  the  tumour,  and  tied  it  also  with  a  ligature,  but 
in  vain  ;  the  pulsation  of  the  tumour  was  still  unaffected.  It 
was  then  necessary  to  operate  upon  the  tumour  itself ;  it  was 
opened  its  whole  length,  and  bled  very  profusely  ;  one  ligature 
only  was  used,  that  ligature  was  struck  with  the  needle  into  the 
centre  of  the  tumour,  where  there  was  one  artery  larger  than 
the  rt  st  ;  but  from  all  the  surface  besides  there  was  one  con- 
tinual gush  of  blood:  the  hajmorrhagv  was  repressed,  and  the 
wound  bound  up  with  a  compress  and  bandage.  The  tumour  in 
short  was  thoroughly  cut  open,  but  it  was  not  cut  out.  It 
healed  slowly,  the  ligature  came  away  with  difficulty  ;  alter  a 
fortnight  the  patient  was  left  to  dress  the  wound  himself;  he  felt 
distinctly,  before  the  wound  was  healed,  that  the  pulsation  had 
begun  again  ;  the  pulsation  became  very  strong,  and  the  tu- 
mour, by  the  time  the  wound  was  actually  healed,  had  attained 

() 


106  Of  the  Aneurism  from  Anastomosis. 

the  full  size  it  had  before  the  operation  ;  it  was  indeed  rather 
lar^rr  than  before. 

But  it  might  easily  have  been  perceived,  that  this  could  not 
be  a  mere  dilatation  of  the  frontal  artery,  for  the  tumour  was 
some  thousand  times  the  diameter  of  that  artery.  The  press- 
ing rhe  point  of  the  finger  upon  both  arteries  stopped  their  pul- 
sation, but  did  not  in  the  slightest  degree  affect  the  tumour  ; 
and  since  the  striking  a  needle  and  ligature  under  each  artery, 
did  not  affect  the  pulse  of  the  aneurism,  it  was  plain  that  the 
tumour  was  of  such  a  nature,  as  to  draw  its  blood  from  a 
variety  of  sources,  and  that  it  was  necessary,  not  to  cut  it  open, 
but  to  cut  it  out. 

For  nine  months  longer  the  tumour  was  suffered  to  grow  un- 
molested. When  Mr.  R first  desired  my  advice,  the  cha- 
racter of  the  tumour  was  very  strongly  marked. 

It  was  very  protuberant  from  the  forehead,  of  a  regular  oval 
form,  about  the  s'-ze  of  a  snii;ll  hen's  egg.  The  scar  of  the  for- 
mer operation,  about  three  inches  long,  ran  across  the  centre  of 
the  tumour.  The  tumour  was  not  purple  on  its  surface,  like 
the  flesh  spots  of  children,  it  was  covered  with  a  firm  and  sound 
skin  ;  the  scar  was  white,  the  rest  of  the  skin  was  of  a  deep 
red,  from  inflammation,  and  not  from  the  blood  appearing 
through  it  ;  its  throbbing  was  exceedingly  strong,  and  of  late  it 
had  become  very  painful,  so  that  he  was  in  fear  of  the.  bursting 
of  the  tumour,  or  the  corruption  of  the  bone  ;  it  was  from  the 
pain,  which  had  of  late  been  considerable,  that  he  was  inclined 
to  ask  advice,  or  to  submit  to  a  second  incision.  The  notes 
taken  at  this  period,  in  relation  to  the  appearance,  size,  and 
pulsation  of  the  tumour,  are  as  follows  : 

The  lower  artery,  the  ocular,  which  comes  from  within  the 
orbit,  is  very  large,  and  is  felt  entering  into  the  lower  corner  of 
the  tumour;  the  temporal  branch  is  very  greatly  enlarged,  is  re- 
markably tortuous,  pulsates  with  great  force,  so  that  I  am  sur- 
prised it  has  not  wrought  out  other  aneurisms  near  this  first  one. 
He  wears  his  hat  quite  off  his  face  ;  when  his  hat  presses  upon 
the  tumour,  it  increases  in  size  ;  when  he  runs,  when  he  is  heat- 
ed, when  he  stoops,  when  he  breathes  hard,  it  increases  in  size, 
and  its  pulsations  are  very  strong  :  when  he  drinks  spirits  or 
wine,  it  swells,  pulsates,  assumes  a  deeper  tinge,  and  every  per- 
son at  table  can  perceive  the  change  ;  and  when  I  handle  it  rude- 
ly, it  swells  up,  and  when  he  chooses  to  retain  his  breath,  it  is 
inflated  like  the  gills  of  a  turkey  cock.  It  is  only  for  ten  days 
that  the  throbbing  pain  has  been  remarkable,  but  that  pain  increa- 
ses, and  as  it  runs  backwards  along  the  course  of  the  artery,  it 
is,  by  compressing  the  artel*)',  in  so-ne  slight  degree  relieved. 
Were  this  aneurism  a  mere  dilatation  of  one  artery,  it  should 


Of  the  Aneurism  from  Anastomosis,  107 

be  emptied  at  once   by  compression,  and  the  continuing  of  that 
pressure,  should  prevent  its  being  filled  again.      But  when  it  is 
compressed  firmly,  it  yields  very  gradually,  as  if  the  veins  re- 
ceived its   blood  ;  the  compressing   of   its  two  great  arteries, 
does  not  prevent  its  filling  again  ;  you  are  able  to  suppress  their 
pulsation,  but  the  aneurism  still  pulsates,  it  throbs  from  the  bot- 
tom, it  rises  very  gradually  when  you  cease  irom  pressing,  and 
soon  fills  to  its  full  size  ;  it  seems  to  receive  its  blood  from  one 
knows  not  what  sources,  from  small  arteries  which  cannot  be 
perceived.     The  sudden  inflation  of  this  tumour,  like  the  gills 
of  a  turkey  cock,  its  various  fulness,  according  to  the  season  of 
the  year,  its  falling  in   autumn  when  the  blood  is  low,  and  its 
rising  in  the  spring  when  the  circulation  is  rapid,  the  variations 
of  it  in  respect  of  fulness,  and  its   colour  varying  according  to 
the  degree  of  turgescence,  its  sudden  puffing  up  upon  taking  wine 
or  using  exercise,  its  slow  subsiding,  and  yielding  in  some  slight 
degree  by  pressure,  and  its  being  so  little  affected  by  compress- 
ing the  great  artery  which  feeds  it,  are  sufficient  indications  of 
its  nature.       All  this  proves,  that  it  is  a  tissue  of  small  arteries 
and  veins,  it  fills   not  like  a  varix,  slowly  ;  there  is,  indeed,  no 
dilated  vein  to  be  seen  near  it;  its  filling  is  by  distinct  throbs, 
it  is  filled  by  its  small  and  numerous  arteries,  and  its  swelling  is 
(like  the  erection  of  the  penis)  produced  by  the  pulsations  of  the 
arteries,  stroke  after  stroke,  pouring  out  their  blood  into  the  cells. 
With  this  view  of  its  nature,  I  was  sure  that  it  was  a  kind  of 
tumour  which  was  not  to  be  cut  open,  but  to  be  cut  out.      Dr. 
Jeffrey,  and  Mr.  Cooper,  surgeon  in  Glasgow,  had  the  goodness 
to  assist  me.     I  tied  this  rampant  temporal  artery  before  touch- 
ing the  tumour,  that  it  might  be  once  more  ascertained    how 
little  this  interruption  of  any  one  artery  could  affect  such  a  tu- 
mour.     The  pulsation  of  the  tumour  was  nothing  affected ;  I 
knew  by  this  what  sort  of  an  enemy  I  had  to  deal  with  ;   I  knew, 
that  if  I  cut  within  the  active  circle  of  this  tumour,  I   should 
have  innumerable  branchings  of  the  artery  to  tie  up ;  but  that  if 
I  cut  wide  where  the  arteries  were  undivided,  and  before  they 
had  formed  their  anastomoses,  I  should  have  to  deal  with  but 
one  or  two.      I  disregarded  the  bleeding,   I  knew  that  I  had  no 
means  of  saving  blood  but  by  making  the  operation  rapid.       1 
made  an  oval  incision  which  comprehended  about  a  fourth  part 
of  the  surface  of  the  tumour;  dissected  the   skin  of  each  side 
down  from  it  rapid !v  ;    I  went  down  to  the  root  of  the  tumour, 
and  turned   it  out  from  the  bone.      The  tumour  was  a  perfect 
cellular  mass,  like  a   piece  of  sponge  soaked  in  blood ;  it  was 
tolerably  solid,  and   dissected  out  very  clean,  in  the  form  of  a 
regular  tumour;  it  bled  furiously  during  the  operation  (that  I 
had   resolved  to  disregard),  but  the   moment  the  tumour  was 


408 


Of  the  Aneurism  from  Anastomosis. 


turned  out,'  there  was  not  one  drop  of  blood,  the  surface  was 
clean,  the  pericranium  quite  bloodless,  the  lower  artery  stood 
wagging  out  of  its  hole  in  the  orbit,  and  I  held  it  with  the  hook 
while  Dr.  Jeffrey  tied  it.  The  upper  tortuous  artery  was  also 
tied ;  the  eyebrow,  which  was  divided  exactly  in  the  middle, 
was  brought  nicely  together,  the  incision  healed  in  ten  da\  s  ; 
the  wound  has  been  now  two  vears  healed,  and  the  scar  is  small, 
reddish,  and  very  little  perceptible,  and  the  two  extremities  of 
the  eyebrow,  which  were  two  inches  distant  at  the  time  of  the 
operation,  are  perfectly  close. 

Plans  of  the  Aneurism  of  the  Forehead. 

Temporal  Artery.         The  suppos  ed  dilatation. 
The  real  state  ofthelnotcuLition 


Temporal 
Artery. 


Ocular  Artery. 

Ocular  Artery. 

But  there  are  varieties  of  this  disease,  which  nothing  but 
a  variety  of  cases  can  explain  ;  and  one  consideration  should 
give  us  a  particular  interest  in  investigating  its  nature  ;  that  if  ne- 
glected, it  becomes  incurable,  and  when  it  is  incurable,  I  think 
it  cannot  fail  to  be  in  time  fatal.  It  becomes  incurable,  when 
having  been  operated  upon  with  a  partial  incision,  instead  of 
being  extirpated,  it  is  but  irritated,  and  grows  till  it  spreads  its 
roots  among  the  adjacent  parts.  It  becomes  incurable  when  it 
occupies  a  great  extent  of  skin  :  It  is  an  incurable  disease  when 
it  effects  any  of  the  viscera.  One  phenomenon  of  this  disease, 
I  think,  is  very  remarkable  ;  often,  in  the  course  of  it,  vari- 
ous sacs  are  formed,  which  receive  sometimes  serum  and  some- 
times blood,  according  to  the  state  of  the  tumour,  so  that  tu- 
mours o!  this  kind  sometimes  burst  like  a  ganglion,  or  great 
salivary  tumour,  discharging  a  thin  serum  like  saliva. 

This  kind  of  aneurism  sometimes  grows  in  the  limbs,  and  to 
a  very  remarkable  size  :  bleeds  profusely,  and  reduces  the  per- 
son to  extreme  weakness,  and  yet  is  easily  cured  ;  for  the  rule 
which  I  have  laid  down,  gives  voua  perfect  command  of  the  dis- 
ease. You  must  not  cut  into  the  tumour  but  cut  it  out.  If  you 
merely  cut  into  it,  the  haemorrhagy  is  terrible,  and  the  cure  im- 
perfect ;  if  you  cut  round  it,  and  at  a  little  distance  from  its 


Of  the  Aneurism  from  Anastomosis.  109 

root,  in  place  of  the  profuse  hsemorrhagy,  from  numberless  ar- 
teries, you  have  but  a  slight  bleeding  from  one  or  two,  which 
are  extremely  small. 

A  tumour  of  this  kind,  which  had  grown  to  a  remarkable 
size,  and  done  infinite  injury  to  the  constitution  oi  the  patient, 
was  extirpated  by  my  friend  Mr.  Harkness.  The  history  of  it 
is  as  follows  : 

**  Jean  Smith,  a  house- servant,  about  thirty-nine  years  of 
age,  had  a  tumour  upon  her  arm  of  a  very  singular  appearance. 
It  was  stated  exact!)  over  the  middle  of  the  triceps  muscle,  on 
the  back  part  ol  the  arm;  but  the  (list use  belonged  merely  to 
the  skin.  The  tumour  had  a  very  firm  fleshy  basis,  and  a  sort 
ol  dead  and  throbbing  pulsation  through  the  whole  thickness  of 
it.  The  tumour  had  something  ot  th  appearance  or  a  scrotum, 
with  an  enlarged  testicle:  It  was  about  tight " or  nine  inches 
long,  the  walls  of  the  tumour  were  very  th'uk  and  fleshy  ;  there 
seemed  to  be  a  sac,  or  rather  many  sacculi  within  the  tumour, 
but  quite  flaccid.  The  tumour  hung  down  flabby  and  pendu- 
lous ;  it  was  ot  a  livid  colour,  as  if  it  contained  blood,  or  the 
remains  oi  blood;  where  it  was  not  blue,  like  a  vein,  it  was 
mottled  oi  a  deep  red,  or  lakey  colour.  This  tumour  had  burst 
often,  and  poured  out  prodigious  quantities  of  blood,  and  at  the 
place  where  it  had  burst,  and  especially  at  one  point,  where  the 
blood  had  always  of  late  been  poured  out,  the  surface  of  the 
tumour  was  covered  with  thick  white  scabs,  as  il  the  bleeding 
orifices  had  been  plastered  up. 

The  historj&f  the  tumour  was  singular.  It  was  about  eigh- 
teen months  belore,  that  there  had  appeared  a  small  purple 
spot  upon  the  back  of  the  arm,  which  soon  grew  into  a  tumour. 
The  tumour  enlarged  slowly,  and  had,  in  the  course  of  five 
months,  attained  to  the  size  of  a  hen's  egg;  then,  for  the  first 
time,  it  burst,  and  discharged  a  great  quantity  of  blood.  The 
blood  was  red  and  florid,  and  thrown  out  with  great  impetus  ; 
but  it  stopped  of  its  own  accord.  It  increased  in  size  from 
this  time  forward  very  rapidly,  and  in  four  davs  more  it  was 
thought  necessary,  by  the  surgeon  in  the  country,  to  open  the 
tumour.  This  was  done  by  incision  ;  there  had  been  a  sac 
formed,  even  at  this  time  ;  a  great  quantity  of  coagulated  blood 
was  taken  out,  the  haemorrhage  was  very  profuse,  from  the 
whole  surface,  but  no  particular  artery  was  seen.  No  vessel, 
great  or  small,  was  taken  up  ;  the  htemorrhagy  was  stopped 
with  flour,  firm  compresses,  and  bandage.  The  wound  was 
healed,  the  tumour  grew,  and,  from  the  size  of  a  hen's  egg,  it 
increased  in  a  few  months  to  its  piesent  dimensions,  of  eight  01 
nine  inches  in  length,  and  six  or  seven  in  breadth. 

But  this  incision  never  healed  entirely  ;  a  succession  of  scabs 


110  Of  Aneurism  from  Anastomosis. 

formed  upon  tfyat  part  of  the  tumour,  and  from  time  to  time 
the  blood  burst  out  from  it  on  the  slightest  accident  or  injury, 
and  most  infallibly  the  hsemorrhagy  returned  at  every  menstru- 
ation. 

Her  menses  continued  regular  ;  at  every  menstrual  period 
she  was  sensible  of  a  heat,  pulsation;  and  swelling  in  the  tu- 
mour ;  at  each  menstruation,  blood  burst  out  atresh  Irom  the 
central  opening  ;  she  lost  immense  quantities  of  blood,  but  still 
the  menses  held  on  their  regular  course,  and  flowed  in  due 
quantity. 

About  three  weeks  before  she  came  under  the  care  of  Mr. 
Harkness,  she  had  her  menses,  the  blood  again  flowed  in  the 
usual  quantity  from  the  tumour  in  her  arm.  The  blood  burst 
out  again  from  her  arm  just  two  days  before  this  second  ope- 
ration was  performed.  The  bandages  which  had  been  kept 
firm  from  the  time  of  the  last  hsemorrhagy,  chanced  to  be  loosen- 
ed and  thrown  aside ;  the  blood,  on  the  day  of  menstruation, 
and  just  two  days  before  the  operation,  burst  out  impetuously, 
and  she  lost  no  less  than  four  pounds  of  blood. 

Operation. — This  haemorrhagy  was  so  dangerous,  and  im- 
plied also  something  so  peculiar  in  the  nature  of  the  tumour, 
that  Mr.  Harkness  very  prudently  called  together  a  full  con- 
sultation, especially  of  the  older  surgeons.  The  tourniquet 
was  applied,  the  foul  cloths  and  tight  bandages  were  taken  a- 
way  from  the  tumour.  It  hung  like  a  thick  and  massy  bag  half 
empty.  Mr.  Harkness  did  not  set  about  the  operation  without 
a  degree  of  apprehension,  nor  were  the  gentlemen,  who  were 
convened  to  see  the  operation,  without  fear  of  a  very  trouble- 
some haemorrhage.  Mr.  Harkness  went  round  the  base  of  the 
tumour  with  two  strokes  of  his  knife  ;  he  separated  the  tumour 
very  rapidly  ;  when  the  tourniquet  was  slackened,  there  was 
not  the  smallest  haemorrhage  ;  the  place  where  the  tumour  had 
been,  remained  almost  clean  of  blood  ;  one  small  artery  bled 
smartly,  and  was  taken  up  with  the  tenaculum.  Those  who 
had  seen  the  alarming  hitmorrhagy  of  the  preceding  day,  were 
astonished,  while  those  who  saw  the  tumour  lor  the  first  time, 
and  had  been  called  together  as  to  an  important  case,  were  al- 
most offended  to  find  themselves  so  formally  summoned  to  at- 
tend on  an  occasion  of  so  little  danger.* 

When  such  tumour  is  seated  among  the  viscera,  or  in  any 
inaccessible  part,  it  must  be  an  incurable,  and,  in  the  end,  a 
fatal  disease.  It  is  likewise  incurable  in  those  cases  when,  al- 
though occupying  an  external  surface,  it  is  of  such  extent  that 

*  Upon  differing  this  tumour,  1  find  it  like  a  placenta,  ftringy,  cellular,  con- 
fiding of  a  confided  tiffuc  of  fmail  arteries,  veins,  and  cellular  fubftance,  like  the 
i'ubflanceof  the  placenta,  or  of  the  womb. 


Of  the  formation  of  Callus.  Ill 

no  operation  can  be  performed.  But  in  ail  cases  in  which  an 
operation  is  practicable,  the  ruk  is,  "  not  to  cut  into  them,  but 
cut  them  out." 


DISCOURSE  IX. 


ON  FRACTURES  OF  THE  LIMBS. 

SECTION    I. 

Of  the  Formation  of  Callus. 

J\  BONE  is  a  well  organized  part  of  the  living  body;  that 
matter,  which  keeps  its  earthy  parts  together,  is  of  a  gelati- 
nous nature  ;  the  earth  of  bone,  to  which  it  owes  its  hardness, 
strength,  and  all  its  useful  properties,  is  deposited  in  the  inter- 
stices of  this  gluten,  undergoing  a  continual  change  and  reno- 
vation ;  it  is  incessantly  taken  up  by  the  absorbents,  and  secret- 
ed again  by  the  arteries.  It  is  this  continual  absorption  and 
deposition  of  earthy  matter  which  forms  the  bone  afr  first,  and 
enables  it  to  grow  with  the  growth  ot  the  body  ;  it  is  this  un- 
ceasing activity  of  the  vessels  of  a  bone,  which  enabled  it  to  re- 
new itself  when  it  is  broken  or  diseased  ;  it  is,  in  short,  by  va- 
rious forms  of  one  secreting  process  that  bone  is  formed  at  first, 
is  supported  during  health,  and  is  renewed  on  all  necessary  oc- 
casions. Callus  is  thus  a  regeneration  of  bone,  organized  by 
the  same  action  with  that  by  which  the  original  bone  is  lormed. 
The  callus  begins  to  be  formed  alter  a  fracture,  as  soon  as  the 
continuity  of  vessels  is  re-established,  and  their  healthy  action 
renewed.*  It  is  not  a  concrete  juice,  deposited  merely  for  the 
occasion  of  filling  up  the  interstice  betwixt  fractured  bones,  but 
a  fair  regeneration  of  new  and  perfect  bone,  with  its  needful 
apparatus  of  arteries  and  veins,  and  of  absorbents,  by  which  its 
earthy  matter  is  continually  changed  like  that  of  the  contiguous 
bone.     Callus,  indeed,  could  hold  no  connexion  with  the  con- 

*  Of  courfe,  the  length  of  time  which  intervenes  between  the  accident  and  the 
formation  of  the  callus  varies ;  where  the  inflammation  is  inconfiderablc  it  proba- 
bly commences  in  a  few  days;  but  where  that  is  violent,  even  though  no  matter 
-  termed,  this  procefs  is  delayed  ur-  nomatory  a&ion  fubfid    . — 


Il2  Of  the  Formation  of  Callus. 

tiguous  bone,  were  it  that  inorganic  concrete  which  was  once 
supposed. 

It  results  from  this  doctrine,  that  callus  is  established  in  a 
renewed  continuity  of  vessels  ;  that  a  soft,  flexible,  and  vascu- 
lar substance  is  interposed  betwixt  the  ends  of  the  broken  bones  ; 
that  a  sort  of  temporary  gland  i-s  organized  lor  th^  generation 
of  bone,  or,  to  speak  not  figuratively,  but  philosophically,  it 
seems  as  if,  by  this  re-union  of  all  the  adjoining  parts,  the  ori- 
ginal constitution  and  proper  organization  of  a  bone  were  re- 
stored. But  for  some  time  the  secretion  of  earthy  matter  is 
imperfect;  it  is  infant  bone,  soft,  flexible,  of  an  organization 
perfect  for  all  the  purposes  of  bone,  but  as  yet  delicate  and  un- 
confirmed ;  not  a  mere  concrete,  like  a  crystallization  of  salt, 
which,  if  interrupted  in  the  moment  of  fornvng,  will  never 
form  ;  not  liable  to  be  discomposed  by  a  slight  accident,  nor  to 
be  destroyed  entirely  even  by  a  rude  shock.  In  its  organiza- 
tion so  far  perfect,  that  when  it  is  hurt,  or  the  bony  secretion 
interrupted,  the  breach  soon  heals  like  the  adhesion  of  soft 
parts,  and  so  the  callus  becomes  again  entire,  and  the  process 
is  immediately  renewed. 

But  as  this  is  a  theory  which  is  to  have  some  influence  on 
your  practice,  it  must  not  be  slightly  treated  ;  but  must  be  sup- 
ported with  something  more  substantial  that  hypothetical  rea- 
soning.    I  shall  proceed,  therefore,  to  state  facts. 

Towards  the  end  of  the  cure  of  a  fractured  limb,  the  patient 
becomes  careless  and  confident,  and  often  by  his  playing  tricks 
with  his  crutches,  or  by  the  crutches  slipping  or  breaking  through 
his  negligence,  he  loses  his  balance,  throws  all  the  weight  of 
the  body  suddenly  on  the  weak  limb,  and  thus  breaks  it  a  se- 
cond time.  And  here  a  phenomenon  presents  itself,  which 
very  strongly  confirms  our  doctrine.  It  is,  indeed,  contrary 
to  the  vulgar  opinion,  but  yet  it  is  certainly  true,  that  when  a 
limb  is  broken  a  second  time,  it  re-unites  more  easily  than  at 
the  first,  and  when  broken  a  third  and  a  fourth  time,  heals  still 
faster  and  faster.  A  little  girl,  a  daughter  of  Mr.  Y.  had  her 
arm  three  times  broken,  and  at  each  time  I  found  it  unite  in 
a  shorter  period  than  the  preceding.  A  young  man,  a  servant 
with  Mr.  G.  having  broken  his  leg,  it  bent  and  broke  under 
him  three  successive  times,  and  at  each  successive  fracture  it 
healed  more  and  more  easily. 

"  An  officer,  whose  leg  had  been  reduced  by  a  French  sur- 
geon, and  who  was  recovered  so  as  to  walk  abroad,  fell  and 
broke  it  a  second  time,  about  the  fiftieth  day  of  the  cure.  The 
limb  being  reduced  and  laid  again  in  splints,  was  so  well  ossi- 
fied in  twelve  days,  that  the  surgeon  took  off  the  splints,  the 
patient  was  able  to  lift  his  leg ;  it  bore  its  own  weight  quite  ea- 


Of  the  Formation  of  Callus.  lis 

sily,  and  by  the  twentieth  day  it  bore  the  weight  of  the  body ; 
he  walked  abroad,  used  all  manner  of  freedom,  and  was  cured 
a  second  time,  and  by  the  twenty-fourth  day,  he  was  able  to 
walk  without  any  other  help  than  a  cane.  But  this  ill-fated  leg 
was  destined  to  be  broken  a  third  time  ;  for,  this  gentleman 
having  mounted  his  horse,  in  order  to  go  and  join  his  troop,  the 
first  step  of  his  journey  was  a  disastrous  one.  His  horse 
plunged  in  among  some  clay  ;  he  fell ;  and  the  horse,  in  kicking 
to  clear  himself,  broke  both  the  boot  and  the  ridtr's  leg.*  This 
third  fracture  was  still  more  easily  re-unittd  than  the  second ; 
for  in  less  than  six  weeks,  he  went  to  his  regiment  with  the  leg 
strong  and  firmly  joined,  and  so  accurately,  that  it  was  not  easy 
to  distinguish  the  broken  leg  from  the  sound  one." 

In  all  these  cases  the  limb  yields;  it  bends  under  the  weight 
of  the  body;  it  is  broken  so  that  it  can  no  longer  support  the 
body,  but  without  any  snapping  or  sharp  splintering  of  the  bone, 
and,  in  general,  without  any  overshooting  of  the  bones,  and 
without  crepitation.  It  is  chiefly  by  the  change  of  shape  in  the 
limb,  by  its  bending  somewhat,  that  you  know  it  to  be  broken. 

Every  accident  ot  such  a  case  is  perfectly  consistent  with  the 
doctrine  which  I  have  laid  down,  and  proves  it  very  strongly. 
Callus  is  really  more  vascular  than  bone  ;  and  of  this  we  are  as- 
sured by  various  prools.  Having  cut  off  the  limb  of  a  soldier, 
whose  leg  had  been  broken  in  America  twelve  years  before,  I 
found,  upon  injecting  the  bone,  that  while  the  bone  itself  re* 
ceived  the  red  colour  of  the  injection  pretty  freely,  the  callus, 
which  goes  in  a  zig-zag  form,  joining  together  the  several  ends 
and  points  of  a  very  oblique  fracture,  was  very  singularly  red. 
The  callus,  then,  is  more  vascular  than  the  bone  which  it  be- 
longs to,  even  at  the  distance  of  twelve  years  from  its  forma- 
tion. This  callus,  unconfirmed  at  the  time  that  it  is  broken,  is 
soft,  and  very  highly  vascular.  When  the  callus  breaks,  many 
of  its  vessels  are  ruptured,  but  some  are  only  elongated,  and  it 
rarely  happens  that  its  whole  substance  is  torn.  You  may  ea- 
sily imagine  how  much  more  readily  the  continuity  of  vessels 
will  be  renewed  within  the  substance  of  the  limb,  when  the  bone 
or  callus  is  surrounded  by  vascular  parts  ready  to  swell  and 
close  up  the  breach,  than  in  any  external  wound.  When  we 
consider  the  perfect  vascularity  of  a  callus,  the  excitement 
which  must  follow  this  partial  rupture,  and  the  full  and  vigo- 
rous circulation  in  vessels  accustomed  to  the  secretion  of  bone, 

•  The  meaning  of  the  horfe  breaking  the  boot,  as  well  as  the  leg,  will  not  be 
undcrftood  by  thole  who  are  not  acquainted  with  the  peculiar  manner  of  accouter- 
ing  a  bidet  or  hack-horfc  in  France.  It  has  two  large  fixed  wooden  boots,  flung 
on  each  fide  of  the  laddie,  and  when  the  rider  mounts,  he  thrufts  his  leg,  boot  an-f 
all,  into  thefc  wooden  boots. 

P 


214  Of  the  Formation  of  Callus. 

we  understand  why  a  fractured  callus  is  more  speedily  re-united 
than  a  broken  bone,  where  nothing  is  prepared  lor  the  genera- 
tion of  new  bone. 

I  think  I  cannot  illustrate  the  condition  of  a  callus,  at  the 
time  that  it  is  broken,  better,  than  by  comparing  it  with  the  con- 
dition of  a  bone,  where,  by  the  perpetual  restlessness  of  the  pa- 
tient, a  proper  callus  has  been  prevented,  where  the  bones  have 
covered  themselves  with  a  sort  of  cartilage,  and  an  unnatural  joint 
has  been  formed ;  where  the  surgeon  makes  an  incision,  turns 
out  the  ends  of  the  bone,  pares  off  the  callus  from  each  end  of 
the  bone,  returns  the  pared  ends  of  the  bone  again  into  their 
place,  and  lays  them  among  the  flesh,  opposite  to  each  other,  and 
sews  up  the  wound ;  then  adhesion  takes  place,  the  communion 
of  vessels,  from  bone  to  bone,  and  also  the  continuity  of  all  the 
surrounding  soft  parts,  is  restored  ;  then  all  the  surrounding 
vessels  are  drawn  into  action,  a  mass  of  parts,  active  and  in  high 
circulation,  is  formed  round  the  broken  bone,  the  blood  and  hu- 
mours are  worked  towards  it,  and  the  vessels  of  the  bone  itself 
being  thus  supported  in  their  new  action,  the  ossific  process  is 
renewed  with  great  energy.  This  is  the  result  of  an  experi- 
ment, or  rather  of  an  operation,  which  has  been  several  times 
performed,  and  particularly  by  Mr.  Park,  of  Liverpool,"]"  and  is 
a  fine  analogy  for  explaining  the  condition  of  a  fractured  callus  ; 
for  in  proportion  as  the  organization  is  advanced,  and  the  parts 
full  of  blood  and  in  high  excitement,  the  second  fracture  is  more 
rapidhy  re-united  than  the  first. 

This  accident,  of  breaking  the  leg  a  second  time,  is  in  no 
case  so  grievous  a  misfortune  as  might  be  imagined;  in  a  very 
ill-reduced  fracture,  I  should  rather  esteem  it  fortunate.  Jt 
was  the  practice  of  surgeons  in  all  ages,  to  snap  the  limb  across 
their  knee  whenever  they  were  ill-pleased  with  the  shape  of  it  ; 
and  although,  in  the  present  day,  such  a  practice  would  be  es- 
teemed a  mark  of  the  grossest  ignorance,  it  is  but  one  example 
out  of  ten  thousand,  where  opinions  which  now  pass  only  among 
the  vulgar,  may  be  traced  to  the  highest  and  most  respectable 
authorities. 

That  the  ancients  had  very  generally  engaged  in  this  practice, 
I  could  easily  prove  by  direct  authority  :  and  men  of  the  first 
eminence  in  our  profession,  the  very  best  surgeons  in  the  world, 
have  been  in  the  practice  of  performing  this  operation.     **  I  was 

•f  This  operation  has  fo  frequently  failed,  that  it  is,  I  believe,  never  now  per- 
formed, liut  to  Dr.  Phyfick,  of  Philadelphia,  we  arc  indebted  for  the  difcovery 
of  another,  much  more  calily  performed,  and  likewife  much  more  fuccefsful.  He 
advifes  a  feton  to  be  paffed  between  the  fractured  ends  of  the  bones,  and  to  be  re- 
tained there  until  a  confiderablc  and  fufficient  degree  of  inflammation  is  excited, 
when  it  may  be  withdrawn,  and  the  limb  treated  as  in  a  cafe  of  recent  fraclure.    ft- 


Of  the  Formation  of  Callus.  1 1 5 

called,"  says  La  Motte,  "  to  a  young  man  of  sixteen  years  of  age, 
who  had  the  thigh-bone  broken  seven  or  eight  weeks  beiore,and 
it  was  so  re-united  that  he  could  not  walk ;  the  broken  thigh- 
bone was  shorter  by  hall  a  foot  than  the  sound  one,  and  he 
called  me,  in  order  to  learn  whether  some  sort  of  shoe  might 
not  be  invented,  by  which  the  leg  might  be  raised  so  as  to  en- 
able him  to  walk. 

I  found  the  bone  broken  about  the  middle  of  the  thigh ;  the 
bones  were  so  awkwardly  joined,  that  they  absolutely  crossed 
each  other.  There  was  a  great  elbow  looking  outwards,  and 
a  proportioned  hollow  within  ;  but  the  lad  being  young  and 
healthy,  and  the  callus  as  yet  soft,  I  formed  the  resolution  of 
setting  the  thigh-bone  again,  in  its  right  shape,  by  extension  and 
counter-extension  ;  for  1  knew  that  the  attempt  could  do  the  bov 
no  harm,  and  I  remembered  from  the  accidental  breaking  of 
the  callus,  that  the  callus  was  long  of  obtaining  its  perfect  con- 
sistence. So,  having  made  his  bed,  and  prepared  bandages  and 
splints,  I  made  a  powerful  extension  by  the  help  of  my  young 
men,  and  pushed  in  this  elbow  with  the  flat  palm  of  one  hand, 
and  resisted  with  the  other.  I  succeeded  perfectly  to  mv  mind, 
so  that,  without  one  crv  from  the  lad,  I  reduced  th's  angle,  and 
made  his  fractured  thigh  as  straight  and  as  long  as  the  other. 
In  a  month  he  was  freed  from  his  splints,  and  walked  without 
pain  or  halting,  while  his  thigh  was  as  straight  as  an  arrow.7'* 

From  this  history,  I  draw  no  rash  conclusions.  I  do  not 
propose  to  break  limbs  when  they  are  almost  healed,  that  they 
may  heal  faster ;  nor  to  take  even  a  crooked  and  unserviceable 
limb  and  lay  it  across  the  knee,  like  La  Motte;  but  I  do,  with 
perfect  confidence,  advise  vou,  to  leave  off  bandages,  which 
you  see  were  originally  designed  for  no  other  use  than  to  mbuld 
and  fashion  the  callus  ;  to  reject  those  long  compresses,  which 
were  bound  so  (irmly  round  the  limb  for  the  same  purpose  ;  to 
use  such  splints  only,  as  when  laid  along  the  whole  limb,  may 
serve  to  maintain  its  posture,  and  preserve  it  steady,  and  to  tie 

*  The  following  cafe,  which  occurred  to  myfelf,  is  fomewhat  analogous  to  that 
of  La  Motte. 

Upon  my  return  to  this  country  from  Europe,  I  found  in  the  family  of  one  of 
my  relations,  a  little  girl  about  ten  years  of  age,  whofe  thigh  had  been  fractured 
about  a  month  before,  by  a  fall  from  a  cherry-tree.  '1  he  limb  had  been  fo  badly 
let,  that  the  fracltured  ends  of  the  bones  over-lapped  each  other  about  an  inch  and 
an  half,  and  the  limb  on  that  fide  was  coniequently  that  much  fhorter  than  the 
found  extremity.  As  the  effect  of  this  would  have  been  lamenels  for  the  reft  of 
the  child's  life,  I  propofed  breaking  the  extremity,  as  from  the  age  of  the  patient 
I  had  no  doubt  of  its  re-uniting.  As  there  was  an  appearance  of  cruelty  in  the 
propofal,  the  family  would  not  agree  to  it.  Upon  this,  I  recommended  that  the 
patient  lhould  have  a  pair  of  crutches,  and  be  allowed  to  walk  about.  This  was 
accordingly  done,  and  in  a  few  hours  I  was  informed,  (lie  had  flipped  down  and 
that  her  thigh  was  again  broken.  I  now  treated  the  fraclure,  and  fhe  got  well  in 
the  ufual  time ;  and  no  difference  is  now  perceptible  between  the  liu:bs.    S. 


116  Of  the  Formation  oj  Callus. 

those  splints  slightly  with  tapes;  to  lay  out  a  broken  thigh 
(since  it  cannot  be  commanded  by  splints)  smoothly  upon  a 
pillow,  and  to  venture,  without  fear  of  hurting  the  callus,  to  ex- 
tend the  limb  anew,  and  lay  it  straight  when  it  is  disordered  and 
shortened.  In  a  simple  fracture  of  the  leg,  it  is  almost  suffi- 
cient to  lay  it  on  a  pillow ;  and  you  have  done  every  thing 
when  you  have  laid  it  lightly  and  easily  in  a  smooth  splint  of 
pasteboard  ;  then  the  patient  himself  is  almost  able  to  keep  it 
right.  In  fractures  of  the  arm,  the  part  hangs  naturally  in  the 
best  posture,  and  requires  but  two  splints  of  thin  pasteboard, 
rolled  gently  with  a  linen  roller ;  and  in  fractures  of  the  fore- 
arm also,  the  limb  preserves  its  natural  length  and  natural  form  ; 
it  rt  quires  merely  to  be  laid  upon  a  long  splint  of  pasteboard, 
with  a  smaller  splint  above,  the  two  splints  secured  with  slight 
tapes  or  ribbons,  and  the  arm  slung  round  the  neck. 

Dismiss,  then,  those  anxieties  about  the  manner  of  rolling, 
and  the  express  degree  of  firmness  which  the  bandages  should 
have  ;  look  no  longer  thus  anxiously  at  the  points  of  the  fingers 
or  toes,  to  see  whether  the  bandage  presses  properly,  so  as  to 
make  those  parts  swell ;  you  are  not  to  draw  the  roller,  so  as  to 
straiten  the  limb  up  to  the  very  point  of  producing  gangrene, 
nor  to  use  any  bandages  that  are  formidable  from  their  strait- 
ness,  nor  any  that  are  even  firm,  except  in  children,  in  drunken 
people,  in  maniacs,  or  in  those  who  are  delirious  with  fever  or 
pain. 

SECTION    II. 

Definition  of  Fractures. 

Having  corrected  some  prejudices,  and  initiated  you  into  the 
history  and  theories  of  this  interesting  subject,  I  propose  next 
to  lay  before  you  the  various  characters  and  distinctions  of  frac- 
tures. 

First,  Simple  fracture  is  that  in  which  the  bones,  though  bro- 
ken, do  not  protrude.  The  soft  parts,  though  inwardly  torn, 
are  but  little  injured.  The  periosteum  is  not  separated  in  any 
remarkable  degree  from  the  bone ;  but  the  periosteum  clings  to 
the  bone,  the  tendons  and  muscles  to  the  periosteum,  and  the 
surrounding  soft  parts  are  so  compressed  around  the  fracture, 
in  consequence  of  the  limb  being  entire,  that  adhesion  soon  takes 
place  among  them.  The  interstices  are  filled  with  a  gelatinous 
effusion,  which  soon  becomes  organic,  and  the  continuity  of  ves- 
gels  is  immediately  restored.  Even  in  a  comminuted  fracture, 
each  little  piece  of  bone  retains  its  connexion  with  the  soft  parts, 
and  lives,  and  is  nourished,  and  re-united  with  the  bone  to  which 
it  belongs,  so  that  when  we  dissect  a  fractured  bone  in  the  first 
days,  we  find  the  periosteum  thickened  like  soaked  shammoy 


Definition  of  Fractures.  117 

leather,  the  soft  parts  glued  together  by  inflammation,  and  the 
secretion  of  bone  beginning  in  separate  points  ;  and  when  we 
dissect  an  old  fracture,  we  find  little  pieces  and  splinters  per- 
fectly consolidated  into  the  callus,  which  had  been  entirely  se- 
parated from  the  bone.  This  case,  then,  requires  nothing  but 
ease  and  quiet,  and  a  favourable  posture  of  the  part.  The  cure 
may  be  resembled  to  the  adhesion  of  an  open  wound,  where 
there  is  immediate  re-union  of  vessels,  no  suppuration,  no  waste 
of  parts,  no  remaining  mark  of  injury,  there  is  a  spontaneous 
and  perfect  cure.  The  cure  is  spontaneous,  the  work  of  nature 
alone ;  the  surgeon  has  nothing  to  care  for  but  the  form  of  the 
limb  ;  to  lay  it  even  at  first,  and  to  redress  its  posture  when  it 
happens  to  be  disordered. 

Secondly,  Compound  fracture  is  that  where  the  fracture  is 
accompanied  with  an  outward  wound,  and  it  is  called  Great 
Compound  Fracture  when  the  bone  protrudes.  And  in  this 
case  the  flesh  is  often  cruelly  mangled,  and  the  bone  shattered 
into  many  pieces,  and  yet  the  parts  retain  (though  not  always) 
their  lite  and  vigour.  The  protrusion  of  the  bone  makes  a  rude 
and  lacerated  cut  ;  the  sott  parts,  as  the  periosteum,  muscles 
and  skin,  are  all  cruelly  mangled,  but  they  are  not  destroyed  ; 
the  periosteum  still  clings  to  the  bone,  the  muscles  to  the  peri- 
osteum, and  the  skin  to  the  muscles  ;  there  is  a  very  shocking 
outward  injury,  but  there  is  happily  no  proportionate  disorder 
of  the  inward  parts.  The  inward  parts  are  lacerated  and 
wounded  by  the  protruding  bone  ;  they  are  hurt  by  the  violence 
(as  the  crushing  of  a  chariot  wheel)  which  caused  that  protru- 
sion ;  but  they  are  still  alive,  still  adhere  to  each  other,  and  give 
mutual  support  ;  no  part  is  so  entirely  killed,  as  by  its  death  to 
draw  on  the  death  of  the  whole.  But  then  these  parts,  though 
not  killed,  nor  separated  from  each  other,  are  so  torn  that  thev 
seldom  re-unite  j  they  run  into  inflammation,  and  the  cellular 
substance  is  so  filled  with  extravasated  fluids,  and  the  bones  so 
crushed,  and  re-unite  with  so  much  difficulty,  that  the  suppura- 
tion is  very  profuse. 

The  case,  then,  which  is  here  defined,  is  a  compound  of  frac- 
ture, with  a  great  suppurating  wound,  not  void  of  danger.  The 
gorged  vessels  are  soon  unloaded  by  a  free  and  timely  suppu- 
ration :  after  the  first  swelling  subsides,  the  parts  become  flac- 
cid, the  matter  profuse,  the  patient  is  in  danger  of  being  ex- 
hausted with  pain  and  fever,  and  the  dangers  of  the  case  are 
chiefly  those  of  a  great  suppurating  wound.  If  we  are  forced 
at  any  time  to  amputate  such  a  limb,  it  is  only  for  want  of 
strength  in  the  patient  to  support  the  pain,  fever,  and  profuse 
discharge  ;  for  through  time  and  care  the  lax  swelling  subsides  ; 
the  suppuration  lessens  in  quantity  ;  the  loose  bones  are  (lis- 


118  Definition  of  Fractures. 

charged :  the  living  bones  (whose  periosteum  still  adheres  to 
them)  though  broken  in  a  way  seemingly  destructive  of  ail  orga- 
nization, recover  their  connexion  with  the  fractured  bone,  in  a 
manner  which  has  long  been  admired.  Of  the  bruised  parts, 
those  which  lie  deep  come  to  be  pressed  into  contact  with  each 
other  ;  the  vacant  spaces  within,  and  the  external  wound,  are 
filled  with  granulations,  and  then  the  continuity  ol  vessels  is  re- 
stored, and  the  callus  is  completed.  This  continuity  of  the  ves- 
sels is  essential  to  the  regeneration  of  the  bone  ;  and  we  see  the 
reason  of  a  phenomenon  which  has  excited  the  surprise,  not  only 
of  Dr.  Hunter,  but  all  surgical  writers  from  time  immemorial, 
viz.  that  during  the  suppuration,  and  while  the  wound  continues 
open,  no  callus,  or  at  least  no  complete  callus,  ever  forms. 

Thirdly,  In  compound  fracture  and  luxation,  where, 
along  with  the  protrusion  of  the  bones,  there  is  a  laceration  of 
ligaments,  tendons,  and  capsule  of  some  great  joint,  the  case  is 
peculiarly  dangerous.  When,  for  example,  the  ankle-joint  is 
burst  up,  the  astragalus  broken  to  pieces,  or  turned  out  through 
the  wound,  the  lower  end  of  the  tibia  shattered  and  protruded, 
and  the  fibula  also  broken,  the  disorder  is  such  as  to  defy  the 
powers  of  nature,  and  art  can  do  but  little.  This  is  of  all  cases 
the  most  perplexing  to  the  judgment,  and  distressing  to  the 
feelings  of  the  surgeon,  who  often  wavers  in  fear  and  anxiety, 
for  some  days  desirous  of  saving  the  limb,  and  yet  fearful  of 
losing  the  patient's  life,  till  at  last  the  fatal  gangrene  appears, 
and  he  feels  most  poignantly  the  fault  he  has  committed,  if,  in- 
deed, the  surgeon  can  be  said  to  have  committed  a  fault,  who 
has  attempted  to  save  a  man's  limb,  though  at  the  risk  of  his 
life.  Yet  the  surgeon,  though  he  has  acted  deliberately,  con- 
scientiously, sensibly  and  humanely  ;  though  he  has  been  sup- 
ported by  the  countenance  of  his  fellow-surgeons  ;  still,  when 
misfortune  comes,  must  feel  himself  unhappy. 

The  French  surgeons,  with  one  accord,  declared  amputation 
to  be,  in  such  cases,  the  only  chance  of  saving  the  life.  Palfin 
says,  "  In  luxations  of  the  ankle,  there  is  seldom  any  thing  to 
be  done  but  amputation."  The  same  is  laid  down  by  Duver- 
ney,  as  an  express,  unconditional  rule  of  practice.  We  do 
not  comply  with  any  such  barbarous  rule  ;  we  take  it  only  as  a 
denunciation  of  the  danger  which  is  observed  to  attend  this  par- 
ticular case  ;  we  keep  our  minds  free  and  unbiassed,  so  that  we 
may  be  able  to  decide  this  question  according  to  the  circum- 
stances. We  know  that  nature  will  do  wonders,  but  they  are 
wonders,  and  we  never  enter  upon  the  attempt  of  preserving  a 
limb  thus  desperately  fractured,  without  awful  hesitation,  and 
when  we  do  venture  to  dilate  the  wound,  and  push  back  the 
bones,  we  feel  all  the  responsibility  of  what  we  have  just  done. 


Definition  of  Callus.  1 1 9 

We  watch  the  appearance  of  mortification  for  some  days,  and 
wait  with  inexpressible  anxiety  the  natural  issue  of  the  case,  life 
or  death.* 

Thus  the  simple  fracture  terminates  in  adhesion  of  the  parts 
inwardly  bruised  and  injured  ;  compound  fracture  ends  some- 
times in  adhesion,  but  more  frequently  in  suppuration  ot  parts 
too  much  bruised  to  adhere  ;  but  the  fracture  of  a  great  joint, 
as  of  the  ankle,  is  attended  with  lacerations  too  terrible  to  ad- 
here, or  even  to  suppurate  easily  ;  this  is  the  case  which,  while 
it  sometimes  suppurates,  is  most  apt  to  terminate  in  gangrene 
and  death. 

Fourthly,  Gunshot  fracture  has  many  dangers  peculiar  to  it- 
self; and  of  all  those  circumstances  by  which,  in  other  frac- 
tures, the  soft  parts  recover  their  healthy  condition,  and  the 
splinters  regain  their  natural  connexion  with  the  bone,  not  one 
can  take  place  in  gunshot-wound  :  for  here  there  is  infinite  loss 
of  substance;  the  bone  is  not  merely  broken,  it  is  destroyed, 
contused,  and  deadened  by  the  blow,  and  condemned  to  the  ab- 
solute exfoliation  of  every  individual  particle  and  splinter  that 
has  been  shaken  by  the  ball. 

From  the  moment  in  which  the  bone  is  struck  by  a  ball,  it 
loses  its  life  and  circulation,  and  all  its  connexions  with  the  soft 
parts.  The  bone  is  deadened  to  some  extent  by  the  force  of 
the  blow ;  it  is  splintered  into  many  pieces  ;  the  periosteum  too 
is  killed  by  the  shot,  so  that,  of  the  injured  or  splintered  pieces, 
not  one  can  recover  its  life,  or  resume  its  connexion  with  the 
living  system. 

Nor  is  the  bone  only  killed,  but  all  the  surrounding  parts  also; 
for  the  bone  is  the  resisting  body  which,  by  receiving  the  force 
of  the  ball,  reverberates  it  upon  the  adjacent  parts;  so  that  that 
portion  of  the  flesh  which  most  immediately  surrounds  the  bone, 
is  particularly  affected,  is  deadened,  and  afterwards  thrown  oft 
in  the  form  of  sloughs. 

These  are  the  accidents  of  this  species  of  fracture,  which  dis- 
tinguish it  from  all  others ;  for  the  death  of  all  the  internal  parts 
insulates  the  broken  bone.  There  can  be  no  adhesion  among 
parts  which  are  actually  dead  ;  the  continuity  of  contused  vessels 
can  in  no  shape  be  restored :  instead  of  a  knotting  of  the  sok 
parts  into  a  vascular  mass,  full  of  life  and  action,  supported  by 
a  continuity  of  vessels,  and  fitted  for  the  generation  of  callus, 
there  is  a  cavity  full  of  fetid   matter,  dead  and  sloughing  flesh, 

*  I  would  recommend,  in  every  cafe  of  compound  luxation  and  fracture  of  the 
ankle-joint,  to  endeavour  to  fave  the  limb,  not  only  becaufe  many  have  been  pre- 
ferred, but  becaufe  I  believe  the  patient  is  more  apt  to  die  where  the  leg  is  taker, 
off  from  gangrene,  than  he  is  from  fymptomatic  fever  and  mortification,  where  it 
is  fuffcred  to  remain.  When  fuppuratioQ  is  once  completely  eftablifhcd,  the  ex- 
tremity may  then  be  removed  with  perfect  fafety,  fhoulcl  it  be  nectflary.     S. 


1 20  Definition  of  Fractures . 

and  insulated  fragments  of  bone  ;  a  narrow  opening,  a  deep  and 
ill-conditioned  wound,  and  a  profusion  of  foul  and  putrid  ichor 
flowing  from  the  narrow  openings,  or  bursting  through  various 
fistulas  from  time  to  time. 

Thus  a  gunshot- wound,  with  a  great  fracture,  resembles  in 
many  points  the  worst  kind  of  caries.  The  detached  bones  are 
discharged  with  difficulty  ;  the  dead  parts  which  have  sloughed 
off,  are  very  slowly  replaced;  it  is  long  before  the  wound  be- 
gins to  heal  from  the  bottom,  or,  in  other  terms,  before  the  con- 
tinuity of  vessels  is  restored,  or  the  mass  of  vascular  substance 
prepared,  in  which  the  callus  is  to  be  formed.  In  short,  the 
parts  are  with  difficulty  regenerated ;  they  are  slow  to  heal ;  apt 
to  run  into  ulcers,  fistulas,  and  collections  of  matter ;  while  the 
patient  is  exhausted  by  pain,  fever,  and  profuse  discharge. 

Having  thus  explained  to  you  the  general  nature  of  a  gunshot 
fracture,  I  believe  you  can  be  at  no  loss  to  imagine  the  peculiar 
difficulties  of  each  case ;  for  where  the  limb  that  is  wounded  is 
small,  there  is  less  destruction  of  parts  j  the  sloughing  is  not 
great,  the  suppuration  is  slight,  and  the  bones  being  near  the  sur- 
face,  the  shattered  fragments  are  easily  discharged.  Thus  it  is 
in  wounds  of  the  radius  and  ulna,  and  of  the  os  humeri. 

But  where  the  bone  is  greater,  the  mass  of  soft  parts  more 
bulky,  the  wound  of  course  deep,  and  the  destruction  of  parts 
proportionably  great,  the  matter  is  apt  to  insinuate  itself  among 
the  muscles,  to  insulate  the  bones,  and  to  make,  in  the  end, 
crooked  and  fistulous  passages,  and  an  almost  incurable  sore. 
Such  are  often  the  consequences  when  the  bones  of  the  leg  are 
broken,  especially  where  the  joints  of  the  ankle  or  knee  are 
concerned. 

But  where  the  bone  is  the  largest  in  the  body,  and  covered 
with  a  great  thickness  of  flesh,  as  in  the  thigh,  there  is  a  very 
extensive  destruction  of  parts,  the  mass  of  disease  is  very  great, 
and  if  the  patient  escape  gangrene  in  the  first  days  of  the  wound, 
he  generally  perishes  afterwards  from  the  fever,  the  incessant 
suffering,  and  profuse  discharge.  From  a  gunshot-wound  in 
the  haunch-bone,  or  in  the  femur,  near  its  neck,  about  the  tro- 
chanters, or  any  where  high  in  the  bone,  not  one  of  twenty  es- 
capes. The  sufferings  of  such  a  person  may  be  easily  imagined, 
since  he  lives,  or  rather,  one  might  say,  continues  dying  for 
five  years,  and  while  he  lies  on  this  bed  of  torture,  with  matter 
running  in  profusion  from  various  fistulas  every  where  sur- 
rounding the  joint,  irregular  callus  shoots  out  in  fantastic  forms 
round  the  bone,  so  as  to  unite  the  bones  in  that  crooked  form  in 
which  he  lies;  yet,  even  while  the  callus  is  thus  forming,  the 
fistulas  being  incurable,  and  the  discharge  profuse,  amputation 
is  impossible,  and  the  patient  expires. 


(      121      ) 


DISCOURSE  X. 


RULES  FOR  THE  MANAGEMENT  OF  SIMPLE, 
COMPOUND  AND  GUN-SHOT  FRACTURES. 


QYSTEM-WRITERS  still  retain  the  old  descriptions  and 
terms  of  art,  of  which  there  is  not  one  that  does  not  imply  an 
absurdity.     Of  these  the   most   conspicuous  are,  extension, 

COUNTER-EXTENSION,   COAPTATION  and    DILIGATION.       The  se 

terms  were  descriptive  ot  operations  which  were  actually  per- 
formed by  the  glossocomas  of  the  ancients,  and  by  the  block  and 
tackle  of  the  modern  surgeons. 

Extension  was  the  fixing  of  lacs  and  bandages  upon  the  low- 
er part  of  the  fractured  limb,  to  which  were  applied  ropes  and 
pulleys,  by  which  the  assistants  pulled.  Counter -extension  was 
the  resistance  which  other  assistants  made  by  tablecloths,  girths 
and  bandages,  put  round  the  pelvis  and  upper  part  of  the  thigh. 
Coaptation  was  the  thumbing  and  working  the  smaller  fragments 
and  the  broken  ends  of  the  bone  into  nice  contact  with  each 
other  ;  but  diligation  was  a  process  which  it  would  take  hours  to 
describe,  as  it  took  hours  to  perform!  of  compresses  applied 
round  the  broken  ends  of  the  bone,  pads  and  cushions  laid  along 
the  sides  of  the  limb,  splints  above  these  compresses  and  cush- 
ions, with  distinct  rollers  for  each  several  stage  of  the  operation. 

But  I  will  describe  the  real  operation  in  plain  words,  in  which 
there  is  no  occasion  for  any  such  terms  as  extension,  counter- 
extension,  diligation,  rope,  pulley,  compress  or  bandage  !  That 
is  indeed  rampant  surgery  !  Were  it  possible  for  a  limb  to  re- 
quire such  extension,  it  never  could  be  maintained.  When  a 
limb,  the  leg,  for  example,  is  broken,  you  need  no  nice  and  cri- 
tical diagnostic  signs  to  distinguish  the  fracture  by  ;  the  broken 
limb  yields  under  the  weight  of  the  body,  the  patient  hears  and 
feels  the  snapping  of  the  bone  at  first,  and  is  sensible,  when  the 
limb  is  moved,  of  that  grating  of  the  broken  ends  of  the  bone 
against  each  other,  which  was  in  the  old  vocabulary  termed  Cre- 
pitation ;  and  the  surgeon,  when  he  begins  to  handle  the  limb, 

Q 


122  Of  simple,  compound  and  gun-shot  Fractures. 

is  sensible  of  the  same  grating,  he  perceives  by  the  bending  ot 
the  limb  that  it  is  broken,  and  there  is  indeed  so  little  difficulty 
in  distinguishing  a  fracture,  that  I  have  never  seen  a  patient  who 
was  not  sensible  ot  his  condition,  nor  heard  of  a  surgeon  setting 
a  sound  limb,  exctpt  by  design.  In  setting  this  broken  limb, 
there  is  no  extension  required  but  such  as  common  sense  would 
direct  you  to  use  if  you  were  not  a  surgeon.  You  lay  the  pa- 
tient in  bed,  and  lay  the  limb  on  a  pillow,  or  if  you  design  to  use 
splints,  you  have  two  long  troughs  or  pieces  of  pasteboard  bent 
into  a  hollow  form,  lined,  or  rather  cushioned,  with  two  or  three 
plies  of  flannel,  and  with  tapes  or  ribands,  four  or  five  in  num- 
ber, attached  to  the  outside  of  one  of  the  splints,  by  which  both 
splints  may,  after  all  is  over,  be  gently  tied  together  with  bow- 
knots,  to  be  slackened  or  tightened  according  to  the  swelling  of 
the  limb  ;  you  also  soak  and  soften  the  pasteboard  a  little,  that 
it  may  take  a  shape  suitable  to  that  of  the  limb. 

A  long  splint  of  this  kind  being  laid  flat  upon  the  bed  by  the 
side  of  the  fractured  leg,  you  desire  one  of  your  assistants  to  ap- 
ply his  hands  broad  round  the  upper  part  of  the  limb,  and  grasp 
it  gently  and  steadily  ;  you  take  the  foot  and  ankle  in  the  same 
manner  in  your  own  hand  ;  you  slip,  perhaps,  your  left  hand  un- 
der the  broken  part  of  the  limb,  and  thus  you  and  your  assis- 
tant carrying,  or  rather  sliding  the  limb  gently  along,  lay  it  upon 
its  pillow  (which  should  not  be  a  common  one,  but  rather  like 
a  mattress  or  settee  pillow  flat  and  firm),  or  upon  its  splint. 

Then  you  begin  to  lay  the  limb  smooth  ;  your  assistant  grasps 
it  again  by  spreading  his  hands  upon  the  thigh,  or  below  the 
knee,  with  the  design  of  extending  along  with  you,  not  by  lift- 
ing the  kg  from  the  pillow,  but  rather  by  spreading  his  hands 
over  it,  pressing  it  down  to  the  splint  or  pillow,  and  steadying 
and  holding  it  by  the  pressure,  while  you,  with  both  hands,  lilt 
the  foot  and  ankle,  grasp  them  gently  but  very  firmly,  raise 
them  a  very  little  from  the  pillow  or  splint,  and  draw  gently, 
steadily,  and  smoothly,  and  when  you  have  extended  and 
smoothed  the  broken  leg  in  a  manner  which  you  almost  suppose 
agreeable  rather  than  painful  to  the  patient,  you  press  it  down 
upon  the  splint,  you  and  your  assistant  both  keeping  the  limb 
steadily  and  gently  pressed  down.  You  keep  it  flat  and  press- 
ed with  all  your  hands  till  it  gets  a  sort  of  seat  and  bed  in  the 
pillow  ;  or  if  splints  are  to  be  applied,  the  limb  is  now  pressed 
against  the  lower  splint ;  the  upper  splint  is  then  laid  above  it 
by  a  third  assistant;  you  now  grasp  the  limb  with  your  hands 
on  the  outside  of  the  soft  and  moistened  splints;  you  grasp  and 
model  them  a  little,  and  when  the  whole  has  taken  a  form,  you 
tie  the  several  tapes  one  after  another,  and  after  having  tied  them 
in  a  general  way,  you  go  over  them  again  one  by  one  a  second 


Of  simple,  compound  and  gun-shot  Fractures.  123 

time,  and  tie  them  a  little  closer,  so  as  to  keep  the  limb  agreea- 
bly firm. 

There  is  in  this  description,  you  perceive,  no  mention  of 
those  high-sounding  terms  which  were  so  peculiarly  descriptive 
of  the  grand  surgery  of  the  old  masters  ;  if  we  must  retain  them 
in  our  modern  nomenclature,  there  should  be  associated  with 
them  no  ideas  of  lacs,  and  pulleys,  and  assistants  pulling  at  a 
fractured  limb.  Extension  means,  the  surgeon  gently  drawing 
out  the  fractured  member  ;  counter-extension  means  no  more 
than  some  friend  or  assistant  holding  it  firm  above  ;  coaptation 
means  only  the  smoothing  of  the  limb  and  grasping  the  fractur- 
ed parts  in  the  hands,  and  pressing  it  so  down  upon  its  piliow 
or  splint  as  to  give  it  a  sort  ot  seat ;  while  the  diligation  is  a 
thing  to  be  quite  forgotten.  There  is  much  virtu*-  in  a  word  ; 
many  a  lameness,  and  not  a  few  gangrenes,  may  be  imputed  to 
this  term  diligation.* 

Yet  these  directions,  though  plain,  simple,  and  manifestly  con- 
sistent with  common  sense  and  the  best  principles  of  pathology, 
will  give  you  little  confidence  unless  you  be  satisfied  that  they 
can  be  safely  applied  to  each  individual  case,  and  that  no  other 
rules  can  be  applied  with  good  effect. 


SECTION    I. 

Rules  for  the  setting  of  Simple  Fractures. 

It  is  manifest  that  a  fractured  limb  needs  only  to  be  laid  even 
and  moderately  steady,  to  be  perfectly  re-united  without  our 
help ;  but  if  a  person  were  drunk,  delirious,  or  maniacal,  it 
would  need  to  be  bandaged  :  for  the  same  reason,  if  a  fractured 
bone  be  in  danger  of  being  moved  by  the  unavoidable  motions 
of  the  body,  or  by  the  natural  functions,  as  respiration,  it  surely 
must  be  bandaged. 

1st,  In  fracture  of  the  humerus  or  arm  bone,  the  patient 
is  not  to  be  confined,  he  is  not  to  lose  his  health  on  account  of 
this  trivial  accident ;  and  since  he  is  to  walk  about,  the  motions 
of  the  body  and  swinging  of  the  arm  would  necessarily  discom- 
pose the  bones,  and  absolutely  prevent  their  re-union.  The 
fracture  of  the  arm-bone  then  is  to  be  set  with  two  small  flat 
splints  of  pasteboard,  lined  with  flannel  and  rolled  with  a  roller 

*  I  here  am  cartful  to  defcribe  the  common  operation,  and  th»t  only  :  there  are 
certain  cafes  afterwards  to  be  mentioned,  efpecially  of  compound  fra&ure,  with 
protrufion  of  the  bone,  where  a  more  powerful  extenfion  is  neceffary,  but  ftill  nei- 
ther pulleys  nor  ligatures  are  ufed,  only,  the  furgeon  fomttimes  twifts  a  hand  tow- 
el round  the  ankle  to  give  him  a  fleadier  hold. 


124  Fractures  of  the  Arm  and  Fore  Arm. 

gently,  but  not  carelessly  applied,  because  the  common  splints 
merely  tied  with  tapes  would  slip  off,  and  because  the  arm  hangs 
naturally  away  from  the  body,  so  that  it  is  easily  rolled. 

n.  B.  When  the  fracture  is  near  the  lower  end  of  the  hu- 
merus, near  the  condyles,  or  in  what  is  improperly  called  the 
neck,  viz.  near  the  head  of  the  bone,  it  is  apt  to  be  more  oblique, 
and  then  firmer  splints,  a  steadier  bandage,  and  more  careiul  pos- 
ture of  the  arm  arc  necessary  ;  and  when  it  happens  that  the 
shaft  of  the  humerus  is  separated  from  its  head,  the  axilla 
should  be  filled  with  a  compress  to  keep  the  bone  out  and  in  its 
right  direction. 

2d,  When  the  fore  arm  is  fractured,  although  one  bone  on- 
ly be  broken,  it  is  easily  distinguished,  because  the  slightest 
turning  of  the  hand  produces  rotation  of  the  radius,  and  con- 
sequent crepitation,  the  radius  being  fractured  ;  whereas,  when 
the  ulna  alone  is  fractured,  the  change  of  shape  is  almost  as 
great  as  if  both  bones  were  broken.  When  one  bone  is  bro- 
ken, the  arm  manifestly  cannot  be  shortened,  and  even  when 
both  bones  are  broken,  the  general  surface  formed  by  the  two 
bones  and  their  interosseous  membrane  is  so  broad,  that  they  are 
fairly  opposed  to  each  other,  and  soon  re-unite.  The  fracture 
of  the  fore  arm  requires  two  flat  splints  which  are  to  be  laid  one 
on  the  inside,  the  other  on  the  outside  of  the  arm,  and  in  place 
of  rolling  the  fore  arm  with  a  roller,  I  usually  tie  the  splints  with 
three  or  four  broad  tapes  or  ribands,  each  about  a  loot  in 
length,  not  connected  with  the  splints,  but  laid  upon  the  table 
under  the  lower  splint  when  the  arm  is  about  to  be  laid  upon  it. 

n.  B.  In  the  fore  arm  I  have  remarked  two  things,  first,  That 
the  hand  must  not  be  turned  in  any  degree,  i.  e.  it  must  neither 
be  in  what  anatomists  call  a  state  of  pronation,  nor  a  state  of 
supination,  but  the  thumb  even  with  the  line  of  the  Radius,  and 
the  little  finger  with  that  of  the  Ulna  ;  and  to  preserve  it  in  that 
position,  the  splint  that  lies  on  the  inside  of  the  arm  must  be 
long  enough  to  reach  to  the  palm  of  the  hand,  so  as  to  keep  the 
wrist  steady,  and  prevent  rolling  of  the  radius  ;  and  this  splint, 
where  it  is  lodged  in  the  palm  of  the  hand,  must  be  a  little  pad- 
ded and  a  little  bent,  so  as  to  let  the  fingers  bend  easily  over  it. 

Observe  also,  that  the  representation  I  have  given  of  the  ad- 
hesion and  massing  of  parts  about  a  fractured  bone,  is  so  far 
true,  that  the  callus  is  formed,  not  by  the  particular  ends  of  each 
individual  bone,  but  by  the  whole  mass  of  bone,  inflamed  peri- 
osteum, and  cellular  substance  ;  whence  it  often  happens,  espe- 
cially in  compound  fractures,  where  the  mass  of  parts  engaged" 
in  the  process  is  great,  or  in  gun-shot  fractures,  where  the  arm, 
from  the  tediousness  of  the  sore  lies  very  long  extended  upon 
its   splint,  that  the  ends  of  the  bones  are  united  in  one  mass  of 


Fracture  of  the  Arm  and  Fore  Arm.  125 

callus,  by  which  the  motion  of  the  radius  is  hindered,  and  of 
course  the  turning  motion  of  the  hand  is  lost.  This  products 
a  more  awkward  and  distressing  kind  of  lameness  than  you 
would  easily  imagine,  the  patient  cannot  carry  any  thing  to  his 
mouth  without  turning  the  arm  at  the  shoulder,  the  tffect  is  the 
same  precisely  with  that  ot  an  anch)losis  of  the  elbow  joint. 
I  saw  several  examples  of  this  at  Yarmouth  in  the  Dutch  hos- 
pital, where  men  shot  through  the  fore  arm  had  been  permitted  to 
remain  in  their  cradles  all  the  time  ol  the  cure,  their  arms  lying  all 
the  while  fiat  and  unmoved,  till  at  last  they  became  immovable. 

3d,  In  fracture  of  the  clavicle,  or  collar-bonl*,  the 
weight  of  the  arm  pulls  down  the  scapula,  lor  in  fact  the  clavi- 
cle is  the  only  connexion  the  scapula  has  with  the  trunk  ;  the 
scapula  itself  only  glides  upon  the  ribs,  without  being  connected 
with  them,  large  muscles  lie  betwixt  the  lower  flat  surface  of 
the  scapula  and  the  thorax.  The  accident  is  easily  distinguish- 
ed, as  the  bone  can  be  telt  in  its  whole  length  ;  perhaps  there 
never  was  a  patient  sober  tnough  to  know  any  thing  ot  his  own 
situation,  who  was  not  conscious  of  the  nature  ot  the  accident 
that  had  befallen  him  when  the  collar-bone  was  broken. 

This  particular  fracture  is  both  rtduced  and  retained,  by  first 
pulling  both  shoulders  strongly  backwards,  and  then  turning  a 
firm  linen  roller  round  the  shoulders,  crossing  upon  the  back,  so 
as  to  leave  the  place  of  the  breast  where  the  tracture  is,  exposed 
and  open ;  for  this  no  more  requires  splints  nor  compress  than 
any  other  fractures,  it  is  only  in  consequence  of  the  weight  of 
the  arm  that  the  fractured  clavicle  requires  firm  bandaging. 

n.  B.  This  particular  fracture  is  rarely  accompanied  with  a 
wound,  nor  is  there  any  difficulty  in  reducing  or  retaining  the 
clavicle  in  its  right  place ;  but  sometimes  it  may  be  useful  to  fill 
the  axilla  with  a  large  compress,  in  order  to  support  the  shoul- 
der and  to  keep  it  off  from  the  thorax,  so  as  to  extend  (if  we 
may  use  such  an  expression)  the  broken  clavicle  to  its  full  length. 
When  the  arm  is  big  and  heavy,  when  the  patient  has  to  com- 
plete his  journey  in  a  carriage,  &c.  it  is  proper  to  add  to  the  fi- 
gure of  8  bandage  round  the  shoulders,  another  bandage  sup- 
porting the  fore  arm  and  confining  it  close  to  the  body.  This 
second  bandage  is  indeed  necessary  in  every  case,  to  prevent  the 
swinging  ot  the  arm  and  the  unavoidable  rolling  of  the  collar-bone. 
In  respect  of  the  fracture  of  the  acromion  process  of  the  sca- 
pula, it  may  be  sufficient  just  to  remark,  that  it  also  is  known  by 
a  falling  forwards  of  the  shoulder,  and  the  place  ol  the  fracture 
is  easily  distinguished  as  the  bone  is  superficial. t  This  fracture 
requires  chiefly  that  the  shoulder  should  be  pushed  upwards,  by 

*  See  what  is  faid  on  this  fubject,  in  chapter  on  Bandages,  page  41.     S. 
f  1  he  finger  muft  be  paffed  along  the  fpine  of  the  fcapiria,  in  order  to  afcertain 
*vhen  this  accident  has  happened.     S. 


1 26  Fracture  of  the  breast  Bone. 

which  the  head  of  the  shoulder-bone,  pressed  upwards  against 
the  fractured  process  of  the  scapula,  raises  it  to  its  right  place. 
In  this  fracture,  the  shoulder  must  be  firmly  bound,  and  the 
fore-arm  particularly  well  supported.* 

4th,  In  fracture  of  the  sternum,  the  broken  bone  is  moved, 
not  by  the  motion  of  the  trunk  or  body,  but  by  respiration :  at 
every  motion  of  the  thorax,  the  patient  is  sensible  of  the  grat- 
ing or  crepitation  of  the  bones ;  the  surgeon  feels  it  with  his 
hand,  and  hears  it  by  approaching  his  ear  to  the  breast.  The 
motion  of  the  broken  sternum  soon  inflames  the  mediastinum 
under  it,  and  by  degrees  the  inflammation  extends  along  the 
pleura  and  whole  of  the  thorax.  There  comes  on  a  frequent 
cough,  and  during  every  paroxysm  of  coughing,  the  crushing 
of  the  fractured  sternum  is  dreadful. 

This  fracture  admits  neither  compress  nor  splints,  and  yet 
it  must  be  kept  perfectly  steady ;  to  do  this,  nothing  is  required 
but  a  simple  swathe  or  bandage  round  the  chest,  but  it  must  be 
so  firm  as  to  prevent  the  respiration  being  in  any  degree  per- 
formed by  the  motion  of  the  thorax  ;  the  motions  of  the  thorax 
must  be  entirely  suppressed  by  the  bandage,  and  respiration 
performed  by  the  diaphragm  alone. 

N*  B.  In  this  fracture,  the  motions  of  the  thorax  being  in- 
cessant, the  re-union  of  the  fracture,  without  bandage,  is  impos- 
sible :  if  you  fail  to  apply  the  bandage,  the  motion  of  the  bones 
will  raise  the  inflammation  to  that  height,  that  the  patient  will 
be  suffocated  by  the  general  affection  of  the  lungs,  or  by  the 
effusion  of  matter  round  the  broken  bone ;  and  the  least  mis- 
fortune that  can  happen,  is  tedious  suppurations  under  and 
around  the  broken  parts  of  the  sternum,  and  caries  of  the  bone 
itself,  so  that  it  becomes  necessary  sometimes  to  apply  the  tre- 
pan. The  bandage  which  we  have  directed,  though  drawn  ve- 
ry firm,  is  far  from  oppressive,  the  patient  feels  it  to  be  rather  a 
relief;  before  the  bandage  is  applied,  the  grating  of  the  bones, 
the  inflammation,  high  breathing,  and  terrible  cough,  are  in- 
creasing every  moment ;  but  no  sooner  is  the  bandage  drawn 
firnVthan  the  crepitation  ceases,  the  pain  is  relieved,  the  cough 
and  high  breathing,  begin  to  abate  ;  and  by  plentiful  bleedings 
and  opiates,  all  comes  right  again,  and  the  patient  is  saved. 

5th.  Fractures  of  the  ribs  are  like  those  of  the  limbs,  simple 
or  compound,  with  or  without  injury  of  the  surrounding  flesh  ; 
and  when  there  is  injury  of  the  adjacent  parts,  it  is  by  the  ribs 

*  There  is  an  accident  to  which  the  fhoulder-joint  is  liable,  which  Mr.  Bell 
has  not  noticed  ;  that  is,  a  fracture  of  the  cervix  fcapuhe.  This  fracture  may  be 
always  afcertained  by  prefling  with  the  finger  upon  the  coracoid  procefs,  and  ro- 
tating the  arm,  when  the  crepitus  may  be  felt.  The  treatment  is  fimple  ;  the  anr 
muft  be  fupported  and  bound  to  the  body,  fo  as  to  prevent  its  motion.     S. 


Fracture  of  the  Ribs.  127 

being  driven  inwards,  so  as  to  wound  the  lungs  without  anv 
outward  wound,  such  as  make  the  inflammation  dangerous. 

If  the  fracture  be  simple,  of  one  or  more  ribs,  it  is  distin- 
guished, and  hardly  distinguished,  by  a  slight  crepitation,  the 
broken  ribs  being  wrought  backwards  and  forwards  under  the 
fingers,  by  the  patient  being  sensible  of  the  grating  of  the  bro- 
ken bones,  and  by  the  sharpness  of  the  pain.  There  is  little 
crepitation,  because  the  ribs  are  so  connected  with  each  other 
by  the  intercostal  ligaments  and  muscles,  that  they  cannot  be 
displaced  ;  each  rib  serves  as  a  splint  to  preserve  the  direction 
of  the  adjoining  ribs.  There  is  no  occasion  for  setting  the  bro- 
ken rib  for  any  compress,  nor  for  any  particular  bandage  ;  but 
to  prevent  motion,  the  heavings  of  the  thorax  are  to  be  sup- 
pressed by  applying  a  table-napkin  firmly  round  the  breast,  as 
in  figure  14,  which,  the  firmer  it  is  applied,  gives  the  more  per- 
fect relief.  This  is  all  that  is  usually  done  ;  labourers  and 
country  men,  with  whom  the  accident  is  frequent,  do  no  more, 
and  seldom  require  advice. 

When  the  rib  has  punctured  the  lungs,  the  air  is  effused,  an 
emphysematous  tumour  is  formed,  crackling  like  a  bladder  half 
full  of  air.  There  is  no  possibility  of  mistaking  the  nature  of 
the  accident :  it  may  in  general  be  disregarded,  for  inflamma- 
tion round  the  broken  bone  soon  closes  the  opening  in  the  tho- 
rax, inflammation  in  the  wounded  part  of  the  lungs  prevents 
the  farther  effusion  of  air,  the  air  already  effused  is  absorbed, 
and  the  tumour  disappears.  But  if  the  effusion  of  air  continue, 
the  whole  body  will  be  inflated,  the  air  passing  along  in  the  cel- 
lular substance  will  inflate  the  scalp  and  eyes,  and  extend 
downwards  to  the  thighs  and  private  parts,  till,  by  its  accumu- 
lation about  the  throat,  it  almost  suffocates  the  patient.  Small 
scarifications  with  the  point  of  a  bleeding-lancet,  are  required 
to  discharge  the  air,  through  which  it  must  be  pressed  ;  they 
may  be  made  occasionally  in  various  parts  ;  they  heal  imme- 
diately. After  the  cellular  substance  is  emptied  of  the  air,  the 
point  where  the  broken  rib  is,  should  be  pressed  with  a  firm 
compress,  to  assist  the  adhesion  of  the  lacerated  parts  surround- 
ing the  fracture. 

6th.  In  fractures  of  the  spine,  there  is  nothing  that  belongs 
to  the  surgeon's  department ;  the  spinal  marrow  is  affected  by 
the  compression  of  the  fractured  bones,  or  injured  by  the  con- 
cussion, just  as  the  brain  is  affected  by  a  blow  on  the  head  ;  but 
it  is  a  kind  of  injury  much  less  accessible  to  the  surgeon's  hand. 
The  spinal  marrow  is  plainly  compressed,  the  patient  loses  in- 
stantly the  power  of  his  lower  extremities,  which  are  cold,  and 
without  feeling,  the  bladder  and  rectum  are  paralytic  ;  the  sur- 
geon needs  to  order  glvsters  daily,  and  to  introduce  the  cathe- 


128  Fracture  of  the  Leg. 

ter.  The  parts  on  which  the  patient  lies  ulcerate  first,  and 
then,  in  spite  of  all  possible  care,  fall  into  gangrene.  Such  are 
the  symptoms,  and  such  frequently  the  manner  of  our  patient's 
death  ;  and  notwithstanding  the  bloody  operations  described  in 
books,  of  making  incisions,  finding  the  fractured  or  luxated 
bone,  and  drawing  it  out  by  the  spines  or  splinters,  there  is  no- 
thing practicable  ;  and  those  very  ignorant  directions,  given  up- 
on the  highest  authorities,  are  dangerous  to  none  but  boys. 
The  cutting  into  the  fractured  vertebra  is  a  dream. 

7th.  In  fracture*  of  the  lower  extremities,  there  is  no  occa- 
sion for  bandages  j*  for  the  patient  lying  in  bed,  the  part  is  in  no 
danger  of  being  moved.  Unless  you  could  invent  a  machine, 
which  could  enable  a  patient  to  walk  or  stand  upon  his  leg,  you 
need  none.  In  all  fractures  of  the  leg,  then,  simple  as  well  as 
compound,  you  merely  lay  the  limb  out  upon  its  pillow  or  splint; 
nothing  but  convulsions,  delirium,  or  mania,  can  endanger  the 
fracture,  or  require  bandaging.  In  laying  a  fractured  leg,  where 
but  one  bone  is  broken,  you  need  be  at  no  pains  about  the  pos- 
ture ;  if  the  leg  lie  easy,  and  the  patient  complain  of  no 
pain,  all  must  be  right ;  but  when  both  bones  are  broken,  you 
must  be  at  pains  to  trace  the  sharp  line  of  the  tibia  with  your 
finger ;  for  that  regulates  the  posture  of  the  leg.  This  you  can- 
not do  at  first,  because  the  general  swelling  hides  the  bone,  but 
you  have  no  fear  of  altering  the  posture  of  the  limb,  and  you 
know  that  the  subsiding  of  the  swelling  marks  the  proper  period 
for  ascertaining  the  posture  of  the  limb. 

N.  B.  In  fracture  of  the  leg,  and  especially  in  compound 
fracture,  you  must  be  careful  to  preserve  the  right  posture  ;  for 
the  limb  is  exceedingly  apt  to  change  its  form  from  day  to  day, 
according  to  the  place  that  the  patient  takes  in  his  bed,  and  the 
posture  of  the  limb  with  regard  to  that  of  the  body.  Two  points 
you  will  especially  attend  to  ;  first,  The  heel  slipping  over  the 
end  or  side  of  the  pillow,  or,  making  by  its  prominence  more 
impression  upon  the  bed  or  pillow,  falls  downwards  ;  and  when 
the  bones  are  re-unitfd,  it  is  found  that  there  is  a  slight  devi- 
ation of  the  tibia  from  the  straight  line  ;  the  bone  appears  a  lit- 
tle prominent  on  the  inside  of  the  leg,  while  the  foot  is  a  little 
turned  outwards,  in  a  lame,  or  at  least  a  weakly  posture  ;  yet 
this  degree  of  obliquity,  though  it  causes  a  slight  awkwardness, 
never  causes  a  great  deformity.  Secondly,  The  strong  mus- 
cles lying  all  on  the  back  part  of  the  leg,  the  fractured  part  is 
more  apt  to  be  bent  in  the  opposite  direction,  so  that  the  bones 

*  Notwithftanding  what  is  here  faid,  I  would  recommend  a  many-tailed  band- 
age over  the  limb,  which  may  be  kept  wet  the  firft  few  days  with  a  folution  of 
acetate  of  lead.  Tapes  ought  to  be  parted  under  the  pillows,  and  tied  with  mode- 
rate firmnefs  over  the  leg,  to  prevent  involuntary  ftarts  and  other  accidents.     S. 


Fracture  of  the  Thigh-Bone,  129 

unite  with  an  angle  at  the  shin.  This  causes  a  grievous  de- 
formity, and  worse  than  that,  products  a  shortening  of  the 
limb,  and  a  halt  in  the  gait,  almost  ;is  remarkable  as  that  which 
arises  from  fracture  of  the  neck  of  the  thigh-bone,  and  the  point 
or  angle  where  the  tibia  projects,  is  apt  to  become  a  sore,  for  it 
is  very  easily  fretted  and  ulcerated.  This  is  especially  to  be 
guarded  against,  and  is  particularly  apt  to  happen  in  compound 
fracture,  where  the  limb,  being  laid  in  a  great  case,  is  plastered 
and  poulticed,  so  that  the  surgeon  hardly  allows  himself  to  see 
now  the  bon<  ■  lie,  and  has  given  such  a  formidable  appearance 
to  the  disordered  limb,  that  he  is  afraid  to  look  at  his  own  work, 
or  to  move  the  leg.  Two  directions  then  may  be  uselul  :  first, 
Always  to  pad  up  the  heel  and  foot  properly,  so  as  not  to  allow 
the  heel  to  sink,  or  the  foot  to  fall  to  one  side..  Secondly,  To 
be  careful  always  to  prevent  the  leg  taking  an  an  hed  form,  with 
an  angle  at  the  middle  of  the  tibia  ;  it  is  impossible  to  keep  the 
foot  too  far  forwards,  or,  in  other  words,  an  angle  in  which  the 
middle  of  the  tibia  was  depressed,  was  never  known  to  happen.* 

8th.  But  in  fracture  of  the  t/ii-h,  there  is  no  possibility  of 
having  anv  relief,  but  by  that  slight  change  of  posture  which 
can  be  accomplished  by  moving  the  bod\ ,  while  the  thigh  itself 
is  kept  as  steady*  as  possible  upon  its  pillow. 

First,  When  the  neck  of  the  thigh-bone  Ut  broken  near  its  tro- 
chanter, von  would  not  leave  the  cure  entirely  to  Nature  ;  you 
would  not  willinglv  believe  that  you  can  do  absolutely  nothing 
for  your  patient  or  friend.  When  you  extend  the  limb,  and 
find  that  vou  have  so  far  replaced  the  broken  bone,  that  you 
begin  to  feel  the  crepitation,  you  cannot  but  wish  to  retain  it 
in  that  place,  and  you  lay  large  and  firm  compresses  upon  the 
trochanter,  the  rising  of  which  marks  the  shortening  of  the 
limb,  and  the  fixing  of  which  would  prevent  that  shortening. 
These  compresses  should  be  pressed  very  firm  by  a  spica  band- 
age rolled  round  the  hip,  as  it  is  in  page  41  round  the  shoul- 
der. A  long  splint  must  next  be  prepared,  of  sufficient  length 
to  reach  some  wav  up  the  side,  m;ide  of  firm  deal  board,  de- 
clining gradually  in  size,  in  proportion  as  the  member  natu- 
rally diminishes  in  size,  covered  well  with  flannel,  that  the  pa- 
tient may  feel  no  hardness.  There  must  be  put  round  the  pel- 
vis a  very  firm  bandage  like  the  topband  of  a  pair  of  buckskin 

*  Whether  fplints  ought  to  be  applied  in  the  firft  inftance,  or  not,  to  a  fractur- 
ed leg,  there  can  be  no  doubt  of  the  neceflity  of  ufing  them  when  the  inflamma- 
tion has  fubfided.  Martin's  whalebone-fplints  are  the  heft,  though  the  common 
wooden  ones  will  anfwer.  They  fhould  be  applied  with  fufficient  fifmnefs,  to  pre- 
vent all  danger  of  the  fractured  bones  being  deranged  by  any  ordinary  accidtnt ; 
the  roller  will  require  re-applying  about  twice  a  week,  during  the  progreis  of  the 
cure  ;  at  each  time  of  doing  this,  the  furgcon  ftiould  afcertain  that  the  bones  arcia 
their  proper  pofition.     S. 

R 


130  Fracture  of  the  Thigh-Bone. 

breeches  ;  and  into  a  slit  in  this  bandage  must  be  fitted  the  top  o4 
the  splint.  The  resistance  which  is  to  elongate  the  limb,  is  to  be 
accomplished  by  the  pressure  of  the  top  of  the  splint  against  this 
circular,  and  therefore  the  circular  must  be  prevented  irom  being 
pushed  upwards  by  a  strap  going  round  under  the  pelvis,  like 
that  of  T  bandage  ;  or  whv  should  we  not  actually  take  the  top- 
band  of  a  pair  of  buckskin  breeches,  keeping  also  a  part  of  the 
thigh  of  the  breeches  to  make  the  pressure  more  general,  with 
a  pocket  something  like  the  fob  or  side-pocket  inverted,  to  slip 
the  top  of  the  splint  into,  as  an  ensign  lodg.  s  the  colour-staff  in 
his  side-pocket  ?  I  need  not  relate  to  you  how,  after  the  chief 
resistance  is  established,  the  limb  may  be  extended  and  secured 
by  lacs  round  the  knee  and  ankle  ;  as  to  the  permanent  exten- 
sion, if  vou  will  attempt  it,  it  must  be  easier  with  the  assistance 
of  this  splint:  after  fixing  your  lacs  or  bandages  round  the  an- 
kle, you  may  bring  one  of  them  round  the  lower  end  or  point 
of  the  splint,  and  extend  it  occasionally,  without  any  ill-looking 
apparatus,  any  apparent  cruelty,  or  real  violence.* 

Secondlv,  When  the  fracture,  in  place  of  being  in  the  neck,  is 
below  the  trochanters  in  the  shaft  of  the  bone,  where  fewer  mus- 
cles are  implanted,  the  retraction  is  less  powerful,  but  still  there 
is  retraction,  and  the  shortening  of  the  limb  must  be  resisted  by 
the  long  splint  of  Duverney  alone  ;  it  is  not  a  torturing  ma- 
chine ;  does  not  grasp  the  limb  at  particular  points,  but  lodges 
the  whole  limb,  and  gives  friction  and  resistance  at  every  point. 

Thirdly,  When  the  thigh-bone  is  fractured  in  the  middle,  there 
is  no  reason,  even  in  the  most  muscular  man,  to  fear  retrac- 
tion, and  the  thigh  mav,  with  all  possible  propriety  and  safety, 
be  laid  smoothly  out  upon  a  pillow,  being  careful  of  the  posture 
of  the  body,  that  it  be  not  higher  than  the  thigh,  so  as  to  gravi- 
tate downwards  upon  it ;  the  thigh  should  be  laid  on  one  side  -r 
should  be  laid  a  little  out  from  the  body,  and  a  little  higher,  (in- 
deed the  body  naturallv  sinks  into  the  bed)  and  the  surgeon 
should  also  be  careful  of  the  posture  of  the  heel  and  foot ;  for 
the  leg  is  apt,  bv  its  weight  and  wrong  inclination,  to  turn  the 
thigh  upon  its  axis. 

Fourthly,  In  fracture  of  the  very  lowest  part  of  the  t/iigh- 
bone,  in  the  part,  adjoining  to  the  condyles,  or  lower  head  of  the 
bone,  the  fracture  is  apt  to  be  verv  oblique  ;  and  sometimes  it 
happens  that  the  bone  is  fractured  so  very  obliquely,  that  the 
effect  is  the  same  as  if  one  of  the  condyles  only  were  broken  a- 
way.     In  this  oblique  fracture  there   is  indeed  no  forcible  re- 

•  Buyer's  fous-cuijfe  might  certainly  be  added  with  advantage  to  this  apparatus , 
whether  the  furgeon  attempted  permanent  extenflon  or  not  ;  nor  rauft  he  by  any 
means  omit  keeping  the  thigh  wet,  as  long  as  there  is  any  danger  of  inflammation, 
with  a  folution  of  acetate  of  lead.     S. 


Fracture  of  the  Thigh- Bone.  131 

traction  of  the  bone,  but  a  continual  tendency  to  obliquity.  Ve- 
ry often  I  have  seen  such  a  fracture  so  ill  cured,  that  there  has 
been  a  shortening  and  weakness  in  consequence  of  the  in-kneed 
posture  of  the  limb,  which  was  both  very  distressing,  and  a  ve- 
ry great  deformity.  Then,  although  there  is  no  occasion  in 
this  fracture  for  any  powerful  machine,  there  is  a  necessiu  tor 
the  perpetual  resistance  of  a  very  strong  splint.  The  leg  turns 
outwards  ;  the  splint  of  firm  fir  board,  >.ic.  is  therefore  to  be  ap- 
plied (with  proper  compresses  to  prevent  pain)  upon  the  inside 
of  the  knee-joint,  and  bound  very  firm  with  circulars  above  and 
below  the  knee.  You  cannot  bend  the  leg  too  much  inwards  ; 
it  always  inclines  to  turn  out. 

n.  b.  In  fracture  of  the  thigh  bone,  we  foresee  a  very  uneasy 
confinement  of  six  weeks  to  the  most  irksome  postures,  and  the 
ease  and  comfort  ot  our  patient  are  principally  to  be  studied. 
He  should  be  laid  on  a  hair  mattress,  which  is  cool  and  firm, 
rather  than  on  a  bed,  in  which  he  is  apt  to  sink  down  ;  and  it 
will  be  of  infinite  advantage  to  him  to  h:ive  a  fine  flat  and  thin 
hair  mattress  cut  into  four  or  six  pieces,  and  the  cut  parts  sew- 
ed again  and  covered  with  pieces  of  sheet  ;  then  first  la\  ing 
boards  in  place  of  the  canvass  across  the  trame  of  the  bed,th^n 
laving  an  entire  mattress  for  the  bottom  of  the  bed,  and  then 
laying  the  several  pieces  ot  the  cut  mattress  according  to  your 
pleasure,  you  can  raise  or  depress  any  part  of  the  body  to  any 
degree,  and  alter  your  patient's  posture  with  the  least  possible 
motion  If  any  other  pillows  be  required,  they  should  be  the 
firm  and  flat  hair-cushions,  like  those  of  a  couch,  and  indeed  the 
best  bed  is  a  couch,  which  friends  and  attendants  can  go  round 
about  in  all  directions,  which  can  be  wheeled  to  the  window,  or 
towards  the  fire,  without  discomposing  the  fracture,  and  which 
should  be  placed  in  some  public  room,  where  the  patient  wiH 
have  as  little  as  possible  of  the  feelings  of  a  sick  bed. 

Yiu  must  have  a  hand-rope  for  the  patient  to  raise  and  move 
himself  by,  without  any  strain  of  the  limbs  or  body,  urinals  and 
bed-pans  tor  his  conveniency,  and  he  must  have  occasionally 
anodynes  to  abate  the  irritation  of  his  confinenv  nt  and  distress- 
ing posture,  and  laxatives  of  castor  oil,  cream  of  tartar,  lenitive 
electuary,  sulphur,  or  whatever  suits  his  constitution,  to  pre- 
vent the  constipation  which  proceeds  from  opiates  and  confine- 
ment. 

9th.  In  compound  luxation  of  the  tibia  and  fibula,  in  that 
where  the  bones  are  broken,  the  joint  burst  up,  the  heads  of  the 
bones  turned  out  through  the  wound  ;  the  astragalus  and  heads 
of  the  tibia,  or  of  the  fibula,  almost  separated,  there  is  such  de- 
struction and  laceration  of  parts,  that  we  are  doubtful  uhtther 
to  attempt  preserving  the  foot  ;  we  can  do  little  more  than  lay 


1J2  Fracture  of  the  Patella. 

the  limb  on  the  sound  side,  and  keep  the  foot  as  nearly  as  pos- 
sible in  its  natural  and  proper  direction.  I  have  sometimes 
seen  the  ankle-joint  wonderfully  distorted,  from  being  fractured 
and  dislocated,  even  without  that  laceration  of  the  skin  which 
constitutes  the  case  of  a  compound  Iracture  ;  and  by  drawing 
upon  the  foot  ven  gradually,  but  powerfully,  and  working  and 
modelling  the  disordered  joint  in  the  hand,  I  have  restored  it 
to  its  right  shape,  have  set  it  with  a  firm  splint  well  covered 
with  flannel,  &c.  and  bound  pretty  firm  with  a  figure  of  8  roller 
round  the  foot  and  ankle. 

n.  B.  In  this  fracture  still  the  tendency  of  the  foot  is  to  turn 
outwards,  and  you  have  to  lay  your  splint  along  the  inner  side 
of  the  ankle-joint,  making  a  small  window  or  opening  in  y  our 
splint  to  receive  the  projection  of  the  inner  ankle.  By  the  re- 
sistance of  this  splint  you  draw  the  foot,  which  is  inclined  to 
turn  outwards  in  a  splay-foot  posture,  inwards  into  a  natural 
one.  It  is  the  process  of  the  fibula  that  guards  the  ankle  on  the 
outside,  and  keeps  the  foot  right ;  and  it  is  the  fracture  of  the 
fibula,  and  the  y  ielding  of  the  outer  ankle,  that  makes  the  foot 
fail  off  towards  that  side. 

I  mention  this  luxation  here,  because  it  is  the  only  luxation 
where  the  head  of  the  bone  being  replaced  does  not  remain  ;  it 
is  the  only  luxation  that  needs  to  be  bandaged  as  a  fracture. 

10th.  In  fracture  of  the  patella,  the  chief  difficulty  is  to  pre- 
serve the  bones  in  perfect  contact  with  each  other,  insomuch 
that  Dr.  Hunter,  unable  to  account  for  the  difficulty  of  accom- 
plishing a  perfect  cure,  imagined  that  the  failing  of  the  usual 
process  in  this  particular  instance,  could  be  owing  to  nothing 
else  than  some  part  of  the  membranes  surrounding  the  joint 
falling  in  betwixt  the  two  bones,  so  as  to  prevent  them  coming 
into  proper  contact. 

In  this  particular  fracture  the  leg  must  be  kept  extended  to 
the  utmost  ;  the  upper  piece  of  the  fractured  patella,  which  is 
rett  acted  to  a  great  distance  above  the  knee,  must  be  smoothed 
and  thumbed  downwards,  and  put  in  as  close  contact  as  possi- 
ble with  the  lower  fragments.  To  put  it  in  close  contact  is  the 
difficulty  :  it  seems  to  be  in  close  contact  at  the  time  of  your 
operation,  and  you  are  only  convinced  that  the  pieces  have  not 
been  in  contact  when  the  cure  should  be  complete ;  for  when 
the  swelling  has  subsided,  when  the  patient  begins  to  walk,  a 
hollow  is  seen  betwixt  the  two  ends  of  the  bone,  and  a  ligament 
of  some  length  is  felt  uniting  them.  The  patient  losing  the 
pulley-like  projection  of  the  patella  or  rotula  (and  the  extensor 
muscle  being  shortened)  is  never  able  to  stand  on  one  leg,  ne- 
ver able  to  bear  up  the  body  on  that  limb,  never  able  to  mount 
a  stair  without  carrying  that  leg  before,  and  is  never  out   of 


Fracture  of  the  Patella,  133 

danger  of  forgetting  himself,  trusting  the  weight  of  the  body 
upon  that  limb,  falling  backwards,  and  so  breaking  the  other 
patella,  or  snapping  the  same  one  a  second  time,  as  I  have  seen 
happen  very  often. 

To  preserve  the  bones  in  absolute  contact,  and  prevent  this 
imperfection  in  the  cure,  is  almost  impossible.  The  swilling, 
before  you  are  called,  is  so  great,  that  in  many  cases  bandage 
cannot  be  applied  for  six  or  eight  days.  When  the  swelling  is 
gone,  the  pieces  of  the  bone  cannot  be  math  to  approach  each 
other,  nor  can  the  bandage,  from  the  remains  ol  the  general 
puffy  swelling,  be  applied  close  to  the  bones.  The  bandaging 
has  been  attempted  in  various  wavs.  The  common  bandage  is 
a  btlt  of  leather  split  like  the  common  leather  retractors,  with  a 
small  opening  in  the  middle  of  the  slit,  lor  receiving  the  pa- 
tella ;  each  ol  the  sides  or  semicircles  of  this  opening  is  padded 
up  with  leather,  so  as  to  make  a  pretty  firm  compress  of  a  cir- 
cular form  ;  and  when  the  bandage  is  buckled  round  the  knee, 
and  drawn  firm,  the  two  sides  of  the  slit  are  ot  course  drawn 
so  close  together,  as  to  press  the  two  pieces  of  the  patella  be- 
twixt them.f 

n.  B.  Before  applying  these  rollers,  they  should  be  all  soaked 
and  wetted  (best  in  spirits)  to  make  them  stick  closer  to  the 
flesh,  and  il  (having  applied  them)  you  are  perfectly  satisfied 
with  their  operation,  you  may  easilv  com  ert  them  into  a  firm 
case,  by  taking  a  glue-pot  and  soaking  them  with  glue,  so  that 
each  turn  of  your  roller  would  stick  to  another,  and  the  whole  to 
the  flesh,  the  knee  being  thus  enclosed  in  a  very  perfect  case. 
Both  during  the  cure  and  for  some  time  after  trie  patient  begins 
to  walk  about,  1  find  it  convenient  and  safe  to  stiffen  the  joint, 
by  laying  a  strong  splint  behind  the  ham,  lest  the  patient  should 
make  a  false  step,  and  the  knee  yield  before  the  ligament  joining 
the  bones  were  become  strong. 

n.  b.  Though  I  prefer  simple  and  moist  rollers,  which  stick 
thus  close  to  the  parts,  yet  there  is  no  doubt  that  the  clumsy 
compress-like  roller  contorted  round  the  knee  in  the  form  of 
figure  of  8,  has  sometimes  succeeded  remarkably  well.  In 
proof  of  this,  remember  what  Meibomius  reports  of  a  tow-herd, 
who  having  broken  his  knee  pan,  made  a  very  perfect  cure  by 
twisting  round  it  a  firm  straw-rope. 

11th,  In  fracture  of  the  OUcrunon  (which  is  another  excep- 
tion to  the  general  rule  of  keeping  a  fractured  limb  gently  and 

f  A  fimilar  roller  paiTed  firmly  from  one  extremity  of  the  thigh  to  the  other,  fo 
as  to  prevent  the  contraction  of  the  cxtenfor  mufcles  of  the  leg,  will  be  ol  great 
lervice.     I  have,  within  this  day  or  two  feen  a  perfon  whole  right  patella  has  litrn 
broken,  and  is  re-unittd  by  a  ligament,  who  lays  that  leg  is  at  f.rongas  tin  i 
The  fpace  between  the  fractured  portions    is  about  half  an  inch.     §. 


1 34  Fracture  of  the  Olecranon. 

pleasantly  bent),  you  must  keep  the  arm  completely  extended,* 
for  the  triceps  muscle  pulls  up  the  olecranon  to  an  incredible  de- 
gree, it  mounts  absolutely  half  way  up  the  arm,  and  although 
you  thumb  it  down  again,  yet  if  you  keep  the  fore  arm  in  any 
degree  bent,  the  interstice  betwixt  the  end  of  the  ulna  and  its 
broken  process  will  be  filled  up  with  bone,  and  the  fore  arm  be 
so  tar  anchvlosed,  that  the  patient  will  never  be  able  to  extend 
it,  for  this  filling  up  of  the  interstice  will  be  just  equivalent  to 
the  lengthening  of  the  ulna. 

In  setting  this  fracture,  you  force  down  the  retracted  olecra- 
non, which  is  broken  away  from  the  end  of  the  ulna,  and  you 
completely  extend  the  fore  arm  so  as  to  make  the  end  of  the  ul- 
na meet  its  broken  process,  you  cover  the  broken  process  with  a 
compress,  and  fix  it  with  a  double-headed  roller,  turned  in  form 
of  figure  of  8  (as  in  bleeding),  making  occasionally  turns  purely 
circular  round  the  broken  part,  and  you  make  all  sure  by  la\  ing 
a  stiff  splint  in  the  bend  of  the  arm,  and  fixing  it  with  a  second 
roller  in  order  to  prevent  the  arm  being  thoughtlessly  bended ; 
indeed,  nothing  in  such  cases  should  be  trusted  to  the  discretion 
of  the  patient. 

n.  b.  In  this  fracture  there  is  abundance  of  callus  :  there  is 
no  danger  of  that  imperfect  and  ligamentous  union  which  takes 
place  in  the  broken  patella,  nor  is  there  any  danger  of  that  pro- 
fusion of  callus,  running  like  molten  lead,  into  the  cavity  of  the 
elbow  joint,  which  was  supposed  to  happen,  and  to  occasion  an- 
chylosis. When  this  fracture  has  been  neglected  or  ill  set,  the 
fore  arm  kept  at  right  angles  with  the  arm,  and  the  person  lamed 
perhaps  in  his  right  arm,  it  has  been  proposed  to  make  incision 
to  cut  out  the  intermediate  callus,  with  the  design  of  setting  the 
bones  properly  with  the  arm  extended  j  an  operation  which  is 
surely  not  impracticable. 

12th,  The  rupture  of  the  Tendo-Achillis,  or  great  back  tendon 
of  the'  leg,  more  justly  ranks  with  fractures  than  with  lacera- 
tions ;  for  while  it  was  considered  as  a  laceration  of  a  soft  part, 
it  was  actually  the  practice  of  surgeons  to  sew  the  ends  of  the 
tendon  together  with  great  embowelling  needles  ;  but  now  be- 
ing ranked  with  fractures  of  the  bones,  it  is  set  like  a  broken 
bone,  like  the  fracture  of  the  patella,  for  example,  and  the  sur- 
geon has  no  care  but  merely  to  smooth  down  the  muscle,  to 
prevent  the  retraction  of  the  tendon,  to  preserve  the  ruptured 
parts  as  nearly  as  possible  in  contact  with  each  other. 


*  It  is  neceflary  in  this  accident  to  ufe  great  care  to  prevent  the  joint  from  be- 
coming ftifffrom  want  of  ufe.  In  the  firft  place  the  fore-arm  ought  not  to  be  ex- 
tended farther  than  is  neceffary  to  allow  the  fractured  ends  to  be  placed  in  contact, 
idly,  Moderate  flexion  and  extenfion  ought  to  be  ufed  as  early  as  the  third  week, 
and  repeated  every  day  or  two  to  as  great  an  extent  as  can  be  fafely  done.  S. 


Rapture  of  the  Tendo-Achillis.  135 

The  tendo-achillis  is  broken  as  the  patella  is,  not  by  a  blow 
or  fall,  but  by  a  sudden  and  violent  exertion  of  its  own  mus- 
cles, in  consequence  of  making  a  false  step,  the  patient  being  in- 
stinctively incited  to  make  an  exertion  too  sudden  and  violent  for 
the  tendon  to  withstand  it ;  an  exertion  which  sometimes,  in 
place  of  tearing  the  tendon,  breaks  the  heel  bone.  When  the 
tendon  is  broken,  the  patient,  from  its  insensibility,  feels  no 
pain,  he  feels  as  if  he  had  been  struck  a  smart  blow  with  a  stick  ; 
it  commonly  happens,  in  dancing,  or  in  making  a  false  step,  as 
in  slipping,  though  not  unfrequcntly  it  happens  when  walking 
apparently  securely  on  even  ground  ;  the  patient  instantly  alls 
down  lame,  the  shortening  of  the  bellies  of  the  gastronemii 
muscles,  the  retraction  of  the  tendon,  and  the  interstice  between 
the  two  ends  of  it  are  perceptible,  and  the  patient  himself  is 
conscious  he  has  broken  the  tendon. 

For  setting  this  ruptured  tendon,  various  machines  have  been 
invented,  and  especially  various  shoes  with  straps  and  buckles 
behind  to  draw  up  the  heel,  while  the  upper  part  of  the  tendon, 
on  the  other  hand,  is  pressed  downwards.  According  to  my 
experience,  this  extension  of  the  toe  and  drawing  upol  the  heel 
are  unnecessary*  ;  the  foot  may  be  safely  left  in  its  natural  pos- 
ture ;  it  is  chiefly  important  to  prevent  the  slightest  contraction 
of  the  gastrocnemii  muscles;  for  this  purpose,  the  calf  of  the 
leg  should  be  smoothed  downwards  with  the  hands,  the  whole 
of  the  calf  of  the  leg  from  the  ham  downwards  must  be  rolled 
with  a  firm  roller,  proceeding  from  above,  but  the  bandage  should 
not  pass  the  biggest  part  of  the  calf,  nor  at  all  approach  the  rup- 
tured part,  nor  even  the  inflammation  and  swelling  which  sur- 
rounds it. 

n.  b.  The  chief  danger  in  rolling  the  leg  in  rupture  of  the 
Tendo-Achillis,  consists  in  approaching  the  part  actually  frac- 
tured. I  was  once  called  to  a  gentleman  whose  whole  leg  from 
ham  to  heel  was  firmly  bandaged  with  a  roller,  the  turns  of 
which  made  deep  impressions  on  the  swelled  ankle  ;  and  at  the 
point  where  the  tendon  was  actually  ruptured,  the  turns  of  the 
roller  (so  firmly  was  it  drawn)  had  sunk  down  very  deep  indeed 
betwixt  the  ends  of  the  tendon,  they  were  thus  separated  to  a 
great  distance  from  each  other,  there  was  no  possibility  of  their 
uniting,  and  had  they  been  left  so,  the  old  gentleman  must  have 
continued  perfectly  lame.  It  was  on  the  fourth  clay  after  the 
accident  that  I  was  called  and  undid  this  bandage,  yet  the  cure 
was  in  the  end  tolerably  perfect.  The  muscle  should  be  well 
rubbed  and  smoothed  down,  and  neatly  rolled,  the  ankle  and  cel- 
lular substance  surrounding  the  ruptured  part  should  be  leftper- 

'   The  cxtenfion  of  the  foot  may  be  of  fervice,and  can  do  no  injury.     S. 


1 36  General  Observations. 

fectly  free,  the  foot  should  be  steadied,  but  kept  quite  on  the 
level,  the  toe  neither  pointed  downwards  nor  upwards,  but  the 
foot  kept  at  right  angles  with  the  leg.  Mr.  Robbard,  surgeon 
(I  believe)  at  Ipswich,  was  so  bold  and  so  honest,  as  to  make 
the  experiment  first  on  his  own  person,  of  just  tving  down  the 
gastrocnemii  firmlv,  but  still  continuing  to  walk  about  all  the 
while  the  tendon  was  rc'-uniting.  This  I  dare  no  more  approve 
of  than  the  firm  bandaging  of  the  ruptured  parts. 

The  tendon  is  generally  a  little  knotty,  especially  when  first 
united  j  sometimes  it  adheres  so  to  the  surrounding  parts,  as  to 
make  the  joint  stiff;  and  always  the  tendon  is  a  little  lengthen- 
ed, and  the  muscles  of  the  calf  somewhat  contracted,  so  that  the 
calf  of  the  leg  seems  to  have  shrunk  upwards  towards  the  ham. 

SECTION    II. 

Conclusion. 

In  this  section,  consisting  altogether  of  rules,  which  should  be 
perfectly  minute,  I  fear  there  must  be  many  omissions  which  I 
shall  hardly  be  able  to  compensate  for  in  the  following  general 
observations. 

First,  It  is  uncomfortable  for  the  young  surgeon  not  to  know 
at  what  period  he  may  venture  to  undo  the  apparatus  in  any  par- 
ticular fracture  ;  for  this  reason,  though  there  can  be  no  specific 
nor  absolute  rule,  yet  surgeons  have  been  at  pains  to  mark  the 
period  in  which  they  suppose  each  individual  fracture  to  be 
healed.  Without  warranting  the  propriety  of  these  rules,  allow 
me  to  mention,  that  authors  say,  the  smaller  bones,  as  the  Cla- 
vicle, the  Ribs,  the  Fibula,  are  curable  in  twenty  days  ;  the 
bones  of  the  Cubitus  or  Fore  Arm,  the  Radius  or  Ulna, 
are  curable  in  thirty  days  ;  the  fractures  of  the  humerus  or 
Thigh  Bone  require  fifty  days  to  re-unite;  though,  to  be  perfec- 
ly  re-united  and  strong,  the  fractured  Thigh  Bone  requires  seven- 
ty days.  But  rules  so  specific  as  these,  mentioning  the  very 
day  on  which  a  fracture  may  be  supposed  to  be  cured,  cannot 
be  useful  without  being  understood.  Allow  me  then  to  ob- 
serve, that  as  it  appears  to  me  the  process  is  either  slower  and 
more  imperfect  in  children,  or  at  least,  in  children  the  bone  is 
more  apt  to  be  broken  again,  we  cannot  indeed  wonder  at  cal- 
lus being  slowly  formed,  since  the  bones  themselves  are  still  in- 
complete and  growing  for  two-and-twenty  years :  in  fractures 
then  happening  in  children,  you  keep  the  roller  and  past*  board 
splint  longer  applied.  Nor  is  it  from  the  slow  formation  of  cal- 
lus that  the  cure  is  delayed  in  fractures  of  the  great  bones  ;  the 
process  is  not  slow  in  proportion  to  the  greater  mass  of  bone 


General  Observations.  137 

that  is  to  be  formed,  perhaps  a  callus  will  form  as  rapidly  round 
the  bone  of  an  ox  as  round  that  of  a  boy,  and  be  as  speedily 
completed  in  fracture  of  the  thighbone,  as  in  fracture  of  the  ra- 
dius, for  every  part  has  vessels  proportioned  to  the  mass  of  cal- 
lus that  is  to  be  formed ;  but  the  cure  is  slow  in  proportion  to 
the  size  of  the  bone,  from  the  larger  bone  having  to  support  a 
greater  weight ;  or  rather  the  mass  of  callus  is  slow  in  acquiring 
firmness  proportioned  to  its  size,  or  to  the  weight  it  has  to  bear. 
It  is  for  this  reason  that  we  are  cautious  of  trusting  the  weight 
of  the  body  too  early  on  a  broken  limb  ;  in  fracture  of  the  hu- 
merus, as  the  arm  hangs  and  does  not  necessarily  carry  any 
weight,  the  patient  may  leave  off  his  splints  in  six  weeks  ;  but 
in  fracture  of  the  thigh  bone,  which  has  to  bear  the  whole  weight 
of  the  body,  we  dare  not  expose  the  unconfirmed  callus  under 
such  pressure,  till  fully  three  months  have  elapsed. 

Allow  me  also  to  observe,  that  on  particular  occasions,  parti- 
cular precautions  must  be  taken  ;  that  while  a  man  is  in  his 
sound  health  and  reason,  no  bandage  nor  splint  is  required  in 
fractures  of  the  lower  extremity ;  but  that  when  a  man  is  mani- 
acal or  delirious,  besides  the  ordinary  precautions  of  splints,  the 
limb,  after  being  set,  must  be  laid  betwixt  two  pillows,  tied  to 
them,  and  the  pillows  in  their  turn  fastened  to  the  bed  ;  that 
when  a  man  has  to  be  carried  far  with  a  fractured  limb,  besides 
being  regularly  bandaged  with  splints,  there  should  be  laid  along 
the  sides  of  the  limb,  above  the  splints,  long  and  firm  pieces  of 
wood  bandaged  like  the  splints,  and  extending  beyond  the  heel 
to  prevent  accidents.  And  finally,  that  in  the  sea  service,  and 
in  the  army,  when  either  an  army  is  to  retreat,  or  an  hospital  to> 
be  moved,  or  when  a  storm  is  expected  at  sea,  the  surgeon 
should  be  as  carefully  advertised  of  the  approaching  storm,  or  of 
the  approaching  movement  of  the  army,  as  any  higher  officer, 
for  he  has  many  precautions  to  take  for  the  safety  and  comfort 
of  his  men. 

The  surgeon  when  he  wishes  to  make  any  part  or  bandage 
particularly  secure,  has  it  in  his  power  to  convert  his  rollers  into 
a  firm  case,  either  by  soaking  the  bandages  in  whites  of  eggs, 
which  soon  hardens  in  a  very  firm  varnish  ;  or  with  the  whites 
of  eggs  may  be  mixed  a  little  flour  and  sugar  to  make  it  into  a 
paste,  or  he  may  apply  any  common  varnish  over  his  bandages, 
as  white  spirit  varnish,  but  that  is  slow  of  fixing,  and  is  very 
thin,  or  he  may  strew  a  little  powdered  rosin  on  his  bandages 
before  they  are  applied,  and  then  by  soaking  the  bandages  with 
spirits  of  wine,  the  rosin  is  dissolved,  and  the  whole  adheres  to 
the  limb  with  very  singular  firmness  ;  or  finally,  the  bandages 
may  be  soaked  with  fine  and  well  made  glue,  which  makes  a 
very  firm  case,  and  is  very  far  from  being  offensive. 

S 


138  Pules  for  Compound  Fracture. 

These  methods  are  all  of  them  more  cleanly,  less  cumber- 
some, and  indeed  I  think  more  effectual  than  the  old  Arabian 
method  of  bidding  a  fractured  limb  in  stucco  or  Paris  plaster. 

Lastly,  I  wouid  observe,  ih.it  though  in  a  fracture  of  the  leg 
or  thigh  bone,  or  of  the  patella,  splints  are  quite  unnecessary 
during  trie  cure*,  \et  when  the  patient  ris*  s  from  bed,  rests  the 
Weight  of  the  body  on  the  fractured  bone,  and  begins  to  be  ex- 
posed to  accidents,  light,  but  firm  splints,  should  be  laid  along- 
side of  the  iimb  ;  while  he  wears  those  splints  he  is  in  a  man- 
ner under  \  our  control,  will  walk  with  restraint,  and  be  careful 
of  using  dangerous  freedoms  with  the  limb,  and  thus  he  may 
be  saved  from  a  second  confinement  more  terrible  than  the  first, 
as  it  is  incurred  by  precipitation  and  rashness. 

SECTION    III. 

Rules  for  Compound  Fracture. 

The  moment  you  arrive  at  the  place  where  your  patient  lies, 
if  called  to  the  spot  at  which  the  accident  happened,  you  must 
proceed  to  extend  the  foot,  while  your  assistants  hold  the  limb, 
and  by  pulling  firmlv,  steadily,  and,  remember,  very  strongly, 
(for  in  this  case  a  good  deal  ot  extension  is  required)  you  get 
the  bone  to  go  back  within  the  integuments,  and  though  perhaps 
you  do  not  get  the  bone  and  the  edges  of  the  wound  arranged 
exactly  to  your  mind,  you  get  the  foot  restored  to  a  right 
direction  with  regard  to  the  leg,  the  bone  tolerably  covered  by 
the  integuments,  the  patient  relieved  in  some  degree  from  the 
pain  of  this  protrusion,  and  the  whole  member  put  in  such  a 
posture  that  vou  can  lay  it  on  a  splint  as  a  safeguard.  There 
are  two  forms  in  which  the  compound  fracture  usually  presents 
itstlf ;  first,  when  the  patient  having  leaped  or  fallen  from  a 
height,  the  bone  is  merely  broken,  and  protruded  perhaps  to 
the  length  oi  some  inches,  then  the  foot  being  extended  and  the 
bone  reduced,  you,  after  laying  scraped  lint  upon  the  wound, 
(which  presently  cakes  with  the  blood)  lay  it  upon  a  stiff  splint, 
made  of  fir  board,  properly  covered  and  padded  with  cloths,  to 
which  the  limb  being  fixed  by  broad  circulars  of  any  common 
ribbon  gently  tied,  and  with  proper  folded  compresses,  put  for 
softness  under  each  of  those  circulars,  the  whole  becomes  pretty 
firm,  and  can  be  carried  with  safety. 

Perhaps  you  have  at  first  only  turned  down  the  stocking,  or 
cut  the  breeches  ;  but  the  patient  being  now  brought  to  his  own 
home,  you  pioceedto  perform  your  operations  more  regularly. 

*  See  note,  page  129.     S. 


Rides  for  Compound  Fracture.  139 

You  have  had  your  patient  conveyed  along  with  all  possible 
tenderness  ;  but  you  now  proceed  to  operations  which  require 
a  degree  ol  harshness,  and  even  of  apparent  cruelty. 

First.  You  prepare  the  bed,  by  lifting  the  mattress  and 
clothes,  and  in  place  ot  the  laced  canvass-bottom,  you  lay  boards 
across  the  bed-frame,  which  make  the  bed  hard,  and  keep  it 
perfectly  level  and  true  during  the  cure.  You  next,  in  place  of 
the  feather-bed,  lay  only  a  mattress  above  the  boards;  tor  a 
feather-bed  permitting  the  patient  to  sink  down,  the  body  gra- 
vitates towards  the  fractured  leg,  so  as  often  to  make  the  bones 
overshoot  each  other,  with  a  dangerous  shortening  ot  the  limb. 
You  next  cut  another  mattress  into  lour  pieces,  and  round  each 
piece  you  sew  a  piece  ot  sheet ;  these  are  laid  over  the  first  mat- 
tress, and  shifted  under  the  patient  trom  time  to  time.  You  then 
lay  a  pillow  for  receiving  the  limb  ;  and  having  laid  your  patient 
on  this  bed  or  couch,  you  proceed  to  cut  off  the  breeches,  stock- 
ings, &c. 

The  first  and  most  important  point  of  practice  I  have  to  teach 
you  is,  how  to  reduce  the  bone  ;   and  to  instruct  you,  I  must  be 
careful  to  represent  the  several  possible  conditions  of  the  parts. 
Let  us  first  suppose  then,  that  the  tibia  protrudes  through  a  very 
narrow  opening,  the  toot  turned  entirely  over  to  one  side  ;  the 
bone,  as  if  strangled  by  the  flesh,  under  these  circumstances,   it 
is    difficult  to  extend  the  limb  so  as  to  get  the  bone  to  go  back 
again  through  the  skin  ;  but  it  is  possible,  and  you  try  it  in  the 
following  manner:  You  lay  the  whole  limb  quitt  flat;  \oumake 
two  strong  assistants,  with  both  their  hands,  grasp  the  leg  very 
firmly  below  the  knee  ;   you  then  grasp  the  loot  firnilv  over  the 
tarsus,  and  behind  the  heel,  with  both  vour  hands,  and  begin  to 
pull  gently,  steadily,  and  very  powerfully,  turning  the  foot  a  little 
trom  side  to  side  ;  you  also  twist  a  hand-towel  round  the  ankle, 
and  take  the  assistance  ot  it  to  give  you  a  firmer  hold  on  the  toot, 
and  to  make  you    pull   more  steadily  and  tquallv.       But  if  the 
bone  will  not  go  back,  you  must  give  the  foot   to  another  sur- 
geon or  assistant,  and  clasp  vour  own  hands  round  the  broken 
part,  and  with  your  thumbs,  without   much  reserve  or  affecta- 
tion ot  delicacy,  endeavour  to  force  in  the  bone,  which  though 
it  needs  this  force  to  reduce  it,  yet  lies  easy  when  it  is  reduced. 
Should  it  be  impossible  to  reduce  the.  bone,  on  account  (>t  the 
narrowness  of  the  wound,  and  its  swelling  and  strangulation, 
you  proceed  to  dilate  the  wound ;  you  try  to  push  in  your  fore* 
finger,  or  your  little  finger,  to  conduit  the  bistoury,  or,  if  ne- 
cessary, you  push  in  the  bistoury,  which  makes  way  for  itself; 
it  is  the  straight  probe-pointed  bistoury  you  use.      You  have 
only  one  danger  to  avoid,  that  is,  the  cutting  of  the  tibial  artery  ; 
and  to  avoid  that,  you  keep  to  the  inner  side  of  the  leg,  and  op- 


140  Rules  for  Compound  Fracture. 

posite  to  the  highest  ridge  of  the  tibia  (not  to  the  outside  of  the 
tibia,  for  the  artery  lies  in  the  middle,  betwixt  the  tibia  and  fi- 
bula ;)  you  run  your  bistoury  forward,  and  carry  it  pretty  deep, 
till  \  our  finger,  which  follows  behind  the  bistoury,  passes  in 
easily,  and  till  you  feel  the  stricture  quite  relieved*.  But  if  you 
find  the  bone  splintered  with  points  and  spiculae,  which  (if  it 
were  reduced)  would  run  into  the  flesh,  instead  of  reducing  the 
bone  in  this  dangerous  condition,  you  cut  off  the  sharper  points 
with  the  cutting  forceps  of  an  amputation-case ;  and  having 
smoothed  the  bone,  you  may  then,  after  dilating  the  wound,  re- 
duce it  safely. 

If  you  find,  at  the  same  time,  the  bone  strangled  by  the  nar- 
rowness of  the  wound,  and  pointed  at  its  extremity,  so  that  it 
would  be  dangerous  to  return  it  among  the  soft  parts  ;  if  you 
are  sensible  that  the  bone  is  broken  so  obliquely,  that  though 
reduced,  it  would  not  keep  its  place,  but  allow  the  other  bone 
to  shoot  over  it,  and  at  the  same  time  so  sharp- pointed  that  the 
spiculse  would  run  into  the  flesh,  you  have  then  to  make  your 
election  betwixt  the  two  operations  of  dilating  the  wound  and 
of  cutting  the  bone ;  and  as  you  prefer  cutting  the  bone,  you 
proceed  not  merely  to  smooth  it  with  the  cutting  forceps  of  the 
amputation-case,  but  to  amputate  it  in  the  following  manner : 
Your  assistant  takes  a  flat  iron  spathula  to  defend  the  soft  parts 
with  from  the  teeth  of  the  saw,  lays  it  flat  under  the  bone  be- 
twixt it  and  the  flesh,  he  holds  it  steady  by  one  or  two  fingers 
on  each  side  of  the  bone,  and  presses  or  draws  it  up  edgeways 
betwixt  the  bone  and  the  flesh,  and  the  spathula  being  thus  fixed, 
you  proceed  to  saw  the  bone,  as  close  as  possible  to  the  wound, 
with  the  small  spring-saw,  commonly  put  into  the  amputation- 
case  for  the  purpose  (though  never  used)  of  sawing  the  finger- 
bones. 

Let  us  next  suppose  that  the  bone  does  not  protrude,  but  that 
a  loaded  wagon  has  passed  over  the  limb,  and  that  the  bones 
have  been  so  crushed,  that  through  one  great  wound  a  large 
piece  of  the  tibia  has  been  squeezed  out ;  that  the  separated 
piece  of  the  tibia  projects,  and  is  easily  pulled  away ;  that  upon 
introducing  the  finger  through  this  lacerated  wound,  you  feel 
the  bones  all  shattered,  the  splinters  loose  and  moveable,  the 
tibia  destroyed  to  a  great  extent,  of  three  or  four  inches,  ac- 
cording to  the  broadness  of  the  wheel,  and  that  upon  insinuat- 
ing your  finger,  you  hardly  distinguish  the  lacerated  flesh  from 
the  bruised  bone.  In  dressing  a  limb  thus  shattered,  you  take 
away  the  pieces  which  are  entirely  loose,  because  they  are  plain- 

"  In  making  thii  incifion  you  muft  keep  the  knife  very  clofe  to  the  bone, 
for  fear  of  wounding  the  pofterior  tibial  artery.    S. 


Rules  for  Compound  Fracture,  141 

\y  destroyed,  and  must  produce  suppuration  ;  you  are  at  pains 
to  get  away  the  sharper  splinters,  though  not  so  entirely  detach- 
ed, because  they  excite  spasms  by  their  immediate,  irritation,  and 
cause  abscess  alter  abscess  till  they  are  discharged  ;  you  use  the 
finger  more  than  forceps  ;  you  would  spare  no  present  pain  in  or- 
der to  put  the  parts  in  a  good  condition  for  laying  easy,  and  reco- 
vering their  healthy  state  ;  and  although  you  would  take  away 
whatever  splinters  might  cause  abscess,  you  would  not  work 
too  long  with  your  finger,  nor  pick  with  your  forceps  too  curi- 
ously, lest  you  should  cause  more  suppuration  by  your  own 
imprudence.  But  I  might  give  you  a  volume  of  directions,  and 
still  be  obliged  to  conclude  at  last,  that  I  must  leave  much  to 
your  discretion  and  good  sense. 

Let  us  next  suppose  that  the  crushing  of  the  bones  is  ac- 
companied with  a  bursting  or  laceration  of  the  arteries;  the 
blood  always  streams  from  the  limb,  and  cakes  about  the  wound 
soon  after;  often  small  arteries  bleed  smartly  at  first,  but  shrink 
before  you  can  attend  to  them,  and  close  entirely  by  putting  a 
little  bit  of  lint  to  the  wound  ;  but  when  the  tibial  artery,  as  of- 
ten happens,  is  wounded,  it  bleeds  so  as  to  require  attention. 
Sometimes  you  have  occasion  for  the  needle,  but  very  rarely; 
for  such  is  the  effect  of  the  laceration,  whether  by  opening  the 
cellular  substance  so  as  to  receive  the  extravasated  blood,  (or 
in  what  other  way  it  is  immaterial  to  determine)  that  even  the 
tibial  artery  stops  by  merely  applying  to  it  a  pellet  of  lint*.  If 
the  artery  continues  to  bleed,  you  must  take  a  piece  of  sponge, 
well  dried,  apply  it  as  close  as  possible  to  the  mouth  ot  the  ar- 
tery, and  make  one  of  your  voung  men  hold  it  down  for  some 
time  with  the  point  of  the  finger.* 

But  there  is  another  kind  of  haemorrhagv  still  more  perplex- 
ing:  the  arteries  are  sometimes  wounded  from  within  by  the 
sharp  bones,  the  blood  is  extravasated,  you  open  a  large  ecchy- 
mosis  with  the  lancet,  in  order  to  prevent  extensive  suppura- 
tion ;  the  extravasated  blood  flows  out,  the  skin  falls  down  again, 
no  more  blood  collects  in  that  place,  and  you  think  all  is  right, 
and  have  no  apprehension  of  any  large  artery  being  wounded, 
when  suddenly,  and  at  the  distance  of  two  or  three  days,  a  con- 
siderable artery  begins  to  bleed  from  the  bottom  of  the  sac,  and 
after  bleeding  outwardly,  it  threatens  (when  prevented  bleeding 
openly)  to  inject  the  whole  limb  with  blood. 

Wherever  an  artery  thus  threatens  to  produce  successive  and 
dangerous  extravasations  into  the  cellular  substance,  )  ou  roust 
cut  up  the  skin  and  muscles  to  the  place  where  the  bleeding  ar- 
tery is,  and  although  sometimes  you  may  have  occasion  to  use 

•   Navcr  trnft  a  wounded  tibial  artery  to  any  thing  but  a  ligature.     S. 


142  Rules  for  Compound  Fractures. 

the  needle,  generally  (even  in  this  kind  of  hasmorrhagy)  you 
have  but  to  apply  a  piece  of  sponge. 

Let  us  next  suppose,  that  in  place  of  the  leg,  the  thigh  itself 
is  tractured.  There  is,  in  this  case,  less  laceration  than  when 
two  bones,  as  the  Tibia  and  Fibula,  are  broken  ;  there  is  in  ge- 
neral one  simple  wound,  and  one  pointed  and  projecting  bone, 
but  the  strangulation  round  the  bone  is  great,  the  reduction  of  it 
by  extending  the  limb  is  almost  impracticable  ;  the  finger  is  not 
allowed  to  pass  into  the  wound,  and  when,  by  a  little  dilatation 
with  the  bistourv,  the  finger  is  admitted,  the  surgeon  feels  sen- 
sibly strong  bridles  of  the  muscular  flesh,  and  considerable  re- 
sistance from  the  tendinous  firmness  of  the  Fascia-lata.  This  is 
the  case  where  (whatever  we  may  determine  as  to  the  pinching 
off"  of  splinters,  or  reducing  the  bone  to  a  right  shape)  we  choose 
to  dilate  the  wound,  both  because  of  its  natural  narrowness,  and 
because  there  would  be  unquestionably  great  danger  of  stricture, 
were  the  Fascia- lata  left  entire  ;  for  when  the  whole  thigh  is 
swelled,  the  tension  of  the  fascia  makes  that  inflammation  run 
into  gangrene,  which  might  otherwise  have  passed  on  to  an  ea- 
sy suppuration,  or  might  almost  have  admitted  of  adhesion. 

In  the  thigh,  then,  so  fleshy  and  muscular,  and  covered  with 
this  firm  Fascia,  the  blunt  bistoury  should  be  carried  pretty 
boldly  forwards,  and  the  wound  very  freely  dilated. 


Of  Dressing  the  Wound. 

When,  after  a  fracture,  the  patient,  by  falling  forwards  upon 
the  broken  limb,  has  forced  the  tibia  or  thigh  bone  through  the 
skin,  the  wound  is  not  large,  the  flesh  is  cut,  and  not  much  lace- 
rated ;  it  is  not  only  possible  to  make  it  adhere,  but  perfectly 
proper  (after  reducing  the  bone),  to  bring  the  lips  as  close  as  pos- 
sible, and  stitch  them  together,  as  you  would  do  the  integu- 
ments after  the  great  operations  of  Hernia  or  Trepan.  When, 
alter  a  more  terrible  accident,  the  limb  being  torn  by  machinery, 
or  by  carriages  passing  over  it,  the  laceration  is  great,  you  may 
be  able,  with  the  help  of  the  needle,  to  bring  two  points  of  the 
wound  together  ;  but  the  sides  can  seldom  be  made  to  meet 
fairly,  stitches  are  seldom  useful,  the  sides  of  the  wound  are  to 
be  generally  supported,  by  laying  small  and  thin  pieces  of  lint 
on  each  side  of  the  wound  ;  these  pUdgitsof  lint  are  soon  soak- 
ed with  blood,  which  cakes  and  adheres  to  the  open  part  ot  the 
wound.  By  making  small  rolls  and  compresses  of  linen  and 
soft  lint,  which  you  lay  upon  the  edges  of  the  wound  (at  those 
particular  points  where  you  apprehend  a  gaping  of  the  lips,  or 
where  you  apprehend  that  suppuration  and  cavities  will  form). 


Rules  for  Compound  Fracture.  143 

you  keep  the  parts  very  close.  You  then  lay  up  the  tails  of  the 
eighteen-tailed  bandage  about  the  limb,  and  though  you  cannot 
use  a  roller  (because  that  would  require  the  lilting  of  the  limb 
from  its  pillow  at  every  turn),  you  give  as  much  firmness  as  pos- 
sible with  the  eighteen- tailed  bandage.  The  steady  firmness 
with  which  you  support  the  parts  helps  the  adhesion,  prevents 
suppurations,  and  hinders  an  afflux  ot  blood  to  the  limb ;  over 
all,  you  may  pour  a  little  of  some  spirituous  balsam,  as  the  Bal- 
samum  Traumaticum. 

When  the  limb  is  thus  dressed,  the  wound  which,  while  the 
bone  protruded,  seemed  so  very  formidable,  is  very  small,  the 
pain  is  relieved,  the  very  firmness  ot  the  limb  is  agreeable  to  the 
patient ;  you  then  apply  the  outside  splints  close  to  the  limb,  tie 
them  moderately  firm  with  their  ribands,  and  having,  perhaps, 
bled  your  patient,  you  give  him  an  anodyne  and  compose  him  to 
sleep  ;  it  is  now  that  a  situation  which  seemed  very  desperate 
is  changed  into  a  state  of  hope  and  expectation. 

Of  the  stage  of  Suppuration. 

Though  you  expect  to  procure  adhesion,  or  at  least  to  make 
some  part  of  the  wound  adhere,  you  are  often  disappointed  ; 
you  are  sensible,  from  the  violence  of  the  fever  and  the  swell- 
ing of  the  limb,  that  mischief  is  going  on  within.  The  dry- 
skin,  the  parched  mouth,  the  thumping  pulse,  the  restlessness  and 
delirium,  continue  for  some  days,  and  there  is  a  blackness  round 
the  wound  threatening  gangrene.  But  this  fever  by  degrees 
becomes  less  violent,  the  livor,  which  proceeded  partly  from 
ecchymosis,  partly  from  the  dark  colour  of  the  inflammation, 
gradually  changes  to  green,  the  great  wound  begins  to  suppu- 
rate and  open  very  wide,  the  whole  limb  swells  to  an  enormous 
degree,  the  skin  and  cellular  substance  are  soft  and  relaxed,  and 
bear  the  impression  of  the  finger,  the  redness  extends  over  all 
the  limb,  and  from  the  particular  hollowness  and  softness  of  cer- 
tain points,  you  are  sensible  that  great  suppurations  are  forming 
within. 

Suppose  you  are  called  to  recover  a  limb  in  this  ruined  con- 
dition, you  first  lav  it  in  a  large  tin  case  which  opens  and  shuts; 
or  upon  a  large  splint  lined  with  sheet-lead.  You  next  wash 
the  limb  with  soap  and  water,  clean  it  from  its  filth,  lay  pieces  of 
fine  spongy  lint  upon  the  wound  and  upon  the  various  openings. 
You  then  make  the  whol".  thoroughly  dry,  and  moisten  the  sur- 
face a  little  with  a  sponge  dipped  in  vinegar  and  spirits.  You 
next  apply  adhesive  plasters  to  the  sound  parts  of  the  limb, 
which  support  it,  and  defend  it  from  the  moisture.  You  lay 
small  cushions  of  folded  lint  to  support  the   hollow  parts,  and 


144  Rules  for  Compound  Fracture. 

lay  scraped  lint  or  small  sponges  to  absorb  the  moisture ;  and 
having  one  or  two  small  pasteboard  splints  covered  with  leather 
(or  covered  rather  from  clay  to  dav  with  clean  linen),  you  lay 
them  along-side  of  the  limb,  and  by  tying  two  or  three  such 
splints  on  each  side  of  the  limb,  pretty  firm,  with  separate  tapes 
or  ribands,  (which  should  lie  always  under  the  limb)  you  give 
a  due  support  to  the  hollow  and  suppurating  parts,  and  a  com- 
fortable  and  general  support  to  the  whole.  The  limb  lies  out 
meanwhile  upon  the  broad  and  general  splint,  which  being  of 
tin,  or  lined  with  sheet-lead,  allows  the  water  with  which  you 
occasionally  clean  the  limb,  to  run  off. 

You  are  careful  to  dress  the  limb  every  morning,  and  per- 
haps to  clean  it  also  a  little  in  the  evening.  By  regular  washing 
and  wiping  with  the  moist  sponge,  you  prevent  those  smells 
which  depress  the  patient's  spirits,  and  injure  his  health  ;  and 
by  laying  clean*  lint  to  the  wounds  twice  a-day,  you  soak  up 
the  foul  matter  ;  by  the  occasional  use  of  spirituous  tinctures, 
you  stimulate  the  skin,  and  keep  it  in  good  condition  ;  by  wash- 
ing the  excoriated  parts  with  salt  water,  you  relieve  the  itching. 
You  examine  the  hollow  and  yielding  parts  of  the  limb  careful- 
ly, and  after  each  fit  of  inflammation,  you  feel  anxiously  with 
the  point  of  the  finger  for  any  abscess  it  may  have  occasioned. 
You  find  new  suppurations  produced,  sometimes  by  the  extra- 
vasations of  blood,  sometimes  by  the  pricking  of  splinters,  or 
sometimes  from  matter  lodging  in  hollow  places  ;  you  open 
such  abscesses  with  the  point  of  the  lancet,  soak  up  the  matter 
with  scraped  lint,  and  lay  small  compresses  upon  the  hollow 
places,  by  which  you  heal  them,  and  make  the  internal  parts 
unite. 

The  importance  of  attending  to  the  general  health,  and  even 
to  the  most  trivial  circumstances  connected  with  the  ease  and 
comfort  of  the  patient,  is  very  great;  you  should  be  careful  to 
have  the  windows  open  and  the  room  ventilated,  to  change  the 
linens,  to  make  your  patient  wash  his  face  and  hands  with  cool 
vinegar  and  water,  and  when  the  matter  is  very  profuse,  to  have 
the  room  fumigated  with  vinegar.  You  give  nourishing  food 
in  small  quantities,  wine  according  to  the  constitution  and  ha- 
bits of  the  patient,  anodynes  according  to  the  degree  of  pain, 
fever,  or  restlessness,  and  laxatives  when  they  are  required. 
You  give  astringents  and  anodynes  when  the  diarrhoea  is  vio- 
lent ;  you  give  sometimes  gentle  emetics  upon  the  attack  of 
nausea  and  fever;  and  as  for  bark,  I  believe,  in  place  of  remind- 
ing you  to  give  it  when  the  suppuration  is  great,  I  must  rather 
(so  common  is  this  prescription)  advise  you  against  overloading 

*  Preffed  fpongc  is  much  better,  as  it  abforbs  a  much  greater  quantity  of  matter.  S. 


Rules  for  Compound  Fracture.  145 

your  patient's  stomach  with  this  heavy  drug !  three  or  four 
drachms  of  bark  is  enough  to  sicken  the  appetite  of  a  man  in 
health,  much  more  ot  a  man  confined  for  six  months  to  lie  on 
his  back. 

How  much  is  due  to  care  and  cleanliness,  you  may  judge 
from  this,  that  in  the  case  of  a  gentleman  who  lies  in  his  own 
house,  we  often  venture  to  save  a  limb,  which,  had  the  accident 
befallen  a  poor  man  lying  in  a  crowded  hospital,  must  have  been 
cut  off. 

Often  it  happens,  from  the  destruction  of  parts,  or  the  un- 
happy circumstances  of  the  patient,  that  all  your  cares  are  una- 
vailing. Every  time  you  examine  the  limb,  you  make  discove- 
ries of  more  extensive  destruction,  you  find  the  whole  limb 
swelling  every  day  more  and  more,  you  find  the  matter  running 
profusely  from  the  openings,  the  openings  increasing  in  number, 
and  the  suppurations  extending  from  the  ham  to  the  heel,  with 
intolerable  fetor,  the  muscles  all  undermined,  and  the  bones  ca- 
rious. You  find  that  you  are  no  longer  able  to  support  the  pa- 
tient's health,  that  repeated  attacks  of  diarrhoea  and  fever  have 
reduced  him  to  extreme  weakness,  and  the  wan  visage,  the  pale 
and  flabby  flesh,  the  hollow  eyes  and  prominent  cheek  bones,  the 
long  bony  fingi  rs  and  crooked  nails,  the  quick,  short  breathing, 
and  small  piping  voice,  declare  the  last  stage  of  hectic  and  de- 
bility- The  natural  powers  are  then  sunk  so  low,  the  appetite 
for  food,  and  even  the  desire  of  life  so  entirely  gone,  that  we 
would  believe  tht  patient  past  all  help,  did  we  not  know  by  ex- 
perience that  it  is  never  almost  too  late  to  amputate  the  limb. 

Now,  it  is  come  to  that  crisis  when  our  patient  must  die  or 
part  with  the  limb  he  has  suffered  so  much  to  save  ;  but  he  is 
wearied  out  with  suffering,  and  consents  easily  to  whatever  we 
advise  ;  and  whatever  the  difference  of  opinion  on  the  first  con- 
sultation, when  the  limb  was  first  laid  on  its  pillow  all  bleeding 
and  shattered,  with  its  bones  projecting  and  its  arteries  torn, 
there  is  none  now  that  it  is  thus  undermined  with  suppurations, 
with  universal  caries  of  the  bones  ;  the  first  was  a  state  of  ex- 
pectation, the  second  is  a  condition  where  we  must  despair. 
When  we  are.  thus  sensible  that  further  attempts  to  save  the 
limb  are  incompatible  with  the  life  of  the  patient ;  when  we  per- 
ceive plainly  that  the  limb  thus  mangled,  shortened,  and  imper- 
fectly cured,  would  be  rather  a  load  to  the  patient,  and  a  perpe- 
tual reproach  to  the  surgeon,  we  perform  amputation.  There 
can  be  no  difference  of  opinion  now,  because  the  experiment 
of  trying  to  save  the  limb  has  been  tried,  and  has  failed. 


(     146     ) 


Of  Gun-Shot  Fracture. 

Gun-shot  fracture  is  the  one  which,  though  by  far  the  most 
formidable,  appears  at  first  the  least  dangerous  ;  it  is  a  small 
circular  wound  which  admits  the  finger,  has  little  sensibility,  is 
often  bloodless,  and  when  the  patient  is  struck,  he  feels  rather 
surprise  than  pain  ;  but  when  the  bones  are  fractured,  the  pain 
is  sometimes  very  exquisite,  and  always  the  wound  degenerates 
in  consequence. of  the  destruction  of  the  bone  into  a  fetid  sore, 
with  fistulas,  foul  matter,  and  a  discharge  of  carious  bones. 

When  a  wounded  man  is  brought  to  you,  you  find,  perhaps, 
one  single  wound  in  the  thigh,  the  limb  bending,  the  bone  bro- 
ken, perhaps  some  large  branch  of  the  profunda  bleeding  pro- 
fusely, and  the  man  faint  and  sick.  You  immediately  lay  him 
in  the  floor  of  the  cock-pit,  or  when  brought  to  your  tent  in  the 
field  of  action,  you  lay  him  upon  a  bed,  or  upon  the  bare  ground. 
You  lay  a  large  splint  (or  any  coarse  board,  any  spar  of  wood) 
under  the  limb,  to  prevent  it  bending  and  being  more  injured  : 
if  the  blood  flows  profusely,  you  thrust  a  piece  of  lint  into  the 
wound,  and  hold  it  steady  with  your  finger  ;  you  call  your 
assistants,  and  one  gives  him  a  cordial,  another  cuts  off  the 
breeches,  while  you,  by  pressing  with  your  finger,  prevent  loss 
of  blood.  The  wound  being  in  the  thigh,  where  strangulation 
from  tension  of  the  fascia  is  to  be  feared,  you  are  more  willing 
to  dilate  the  wound ;  and  the  bone  being  shattered,  and  a  large 
artery  bleeding,  (for  in  a  gun-shot  wound  no  small  artery  ever 
bleeds)  make  the  dilating  of  the  wound  a  matter  of  absolute 
necessity.  Your  finger  then  being  kept  steady  upon  the  wound, 
is  to  conduct  your  bistoury  ;  you  lift  your  finger,  draw  out  the 
bit  of  lint,  pass  vour  finger  into  the  opening,  push  in  your  probe- 
.  pointed  bistoury  upon  the  finger,  and  as  you  open  the  wound, 
you  push  your  finger  deeper,  until  you  feel  distinctly  the  jet  of 
warm  blood  ;  then  fixing  the  point  of  your  finger  fairly  upon  the 
mouth  of  the  artery,  you  lay  it  open,  and,  according  to  its  size, 
either  tie  it  with  the  needle,  or  suppress  the  bleeding  by  press- 
ing a  morsel  of  dry  sponge  down  upon  it. 

Your  assistants  now  extend  the  limb,  and  hold  it  very  steady  ; 
while  you  push  your  finger  deeper  into  the  wound,  you  hook 
out  the  splinters  of  the  bone,  then  you  feel  a  piece  of  cloth,  or  a 
button  of  the  breeches,  and  with  the  help  of  a  probe,  or  lever, 
or  dressing-forceps,  you  hook  it  out  ;  you  find  a  piece  of  the 
ball,  and  also  pick  it  away,  but  you  are  sensible  that  the  rest  of 
the  ball,  or  that  one  of  two  balls,  with  which  your  patient  was 
■shot,  lies  very  deep  ;  you  find  the  wound  extending  beyond  the 
reach  of  your  finger;  you  find  that  it  has  passed  almost  through 


Of  Gun-Shot  Fracture.  147 

the  thigh,  and  having  reason  to  believe  that  the  ball  is  near  the 
skin  on  the  opposite  side,  you  make  an  incision  there,  (called  a 
counter-incision)  and  extract  the  ball,  together  with  whatever 
splinters  of  bone  are  driven  to  that  side. 

The  shot  having  passed  through  the  thigh-bone,  you  get  out 
the  ball,  pieces  of  bones,  cloth,  buttons,  keys,  sword,  belt,  and 
other  foreign  bodies  in  this  way,  with  the  finger  :  when  the  shot 
has  passed  through  the  fore-arm,  or  tibia  and  fibula,  or  through 
a  group  of  bones,  as  the  carpus  or  tarsus,  it  is  sometimes  useiul 
to  draw  a  slip  of  dry  linen  through  the  wound  with  your  long 
iron  probe. 

The  wound  being  thus  cleared,  you  proceed  to  dress  it,  not 
with  any  expectation  of  procuring  adhesion  :  that  in  gun-shot 
wounds  is  impossible  :  you  never  pretend  to  stitch  a  gun-shot 
wound.  You  put  adhesive  plasters  round  the  limb,  because 
you  know  that  it  must  lie  long  soaking  in  suppuration  ;  you 
bring  the  wound  close  together  with  compresses  upon  the  sides 
of  it,  a  piece  of  fine  lint  over  the  mouth  ot  the  wound,  and  you 
bind  it  with  a  strip  of  fine  linen.  You  lay  the  member  on  a  firm 
splint,  or  case  of  tin,  to  prevent  any  bending  of  it,  and  )  ou  dress  it 
always  perfectly  dry  ;  you  pour  sometimes  a  little  spirits  upon 
it,  using  no  poultice,  nor  any  thing  but  compresses  of  dry  lint, 
padded  splints,  and  circulars  of  ribbon  to  tie  them  with,  and 
to  support  the  limb.  You  should  never  forget  this  circum- 
stance, that  the  rangers  in  the  woods,  who  never  are  within  a 
house,  who  are  continually  exposed  to  fresh  air,  in  constant  mo- 
tion, and  living  from  necessity  on  a  spare  diet  of  the  coarsest 
kind,  who  merely  bind  up  their  wounds  with  a  piece  oi  lint  and 
a  slip  of  linen,  recover  to  a  miracle  !  while  those  who  are  nearer 
what  is  called  help,  who  are  thrown  into  a  foul  hospital,  and 
who,  if  they  are  able  to  walk,  loiter  about  in  idleness  and  nasti- 
ness,  or  who,  if  wounded  in  their  lower  extremities,  lie  with 
oils,  poultices,  and  rancid  ointments,  applied  to  their  limbs,  in- 
fallibly sicken  and  die. 

In  the  progress  of  such  a  wound,  the  sloughs  will  come  away 
spontaneously  ;  the  suppuration  need  be  encouraged  in  no  other 
way  than  by  supporting  the  general  health ;  the  carious  bones 
will  usually  be  discharged  of  their  own  accord  ;  perpetual  care 
is  required  in  keeping  the  wound  clean,  close  and  dry.  The 
way  of  curing  the  fistulous  sores  that  remain  after  gun-shot 
wounds,  has  been  already  explained. 

Of  Compound  Fracture  and  Luxation,  when  the  Joint  is  distort- 
ed, the  Bones  fractured,  and  the  Integuments  lacerated. 

It  is  in  the  lower  extremity  only,  which  bears  the  whole 


148  Of  Compound  Fracture  and  Luxation. 

weight  of  the  body,  that  we  are  to  look  for  such  complication 
of  injury  as  is  described  in  these  words ;  and  however  a  com- 
pound fracture  of  the  arm,  or  fore-arm,  may  destroy  the  part 
itself,  life  is  actually  in  danger  only  in  great  fractures  ot  the 
lower  extremity,  which  forms  so  great  a  proportion  of  the 
whole  body.  Whether  the  Tibia  only  is  protruded,  or  the  as- 
tragalus displaced,  or  both,  you  perform  the  same  operations  ; 
and  whatever  mav  be  the  decision  of  a  consultation  afterwards, 
your  duty  is  immediately  to  replace  the  foot,  and  close  the 
wound.  Always,  you  proceed  in  the  first  instance  as  if  you  had 
no  doubt  of  saving  the  limb. 

In  general  it  happens,  that  the  Astragalus  or  Tibia  having 
burst  through  the  integuments,  the  bones  are  so  strangled  in  a 
small  slit  or  opening,  that  no  degree  of  force  will  reduce  them  ; 
you  do  not,  in  this  case,  cut  off  a  bone  so  necessary  to  the  joint 
as  the  inner  process  of  the  tibia  ;  you  never,  unless  it  be  already 
entirely  separated,  cut  away  the  astragalus;  \ou  first  extend  the 
foot  very  powerfully,  and  press  in  the  astragalus,  and  try  to  re- 
duce the  bonrs  ;  but  failing  in  this,  you  make  a  free  incision, 
taking  care  to  avoid  the  tibial  arttries  ;  extend  the  foot,  replace 
the  astragalus  betwixt  the  processts  of  the  Tibia  and  Fibula, 
and  having  closed  the  wound,  you  lay  a  piece  of  lint  upon  the 
lips  of  the  laceration.  You  then  place  the  limb  on  a  large  and 
stiff  splint,  in  a  manner  which  surely  I  need  not  explain,  and 
with  surh  pillows,  compresses,  and  bandages,  as  you  find  neces- 
sary for  keeping  the  foot  in  its  right  position,  with  regard  to  the 
leg. 

The  limb  being  thus  laid,  you  are  not  to  promise  yourself 
absolute  success,  but  the  surgeons  whom  you  have  sent  for  be- 
ing arrived,  you  consult  together  upon  the  probable  event  of  the 
case  ;  and  so  very  favourable  is  the  aspect  that  matters  assume 
after  those  operations  have  been  nicelv  performed,  that  the  con- 
sultation will  very  rarely  order  the  limb  to  be  cut  off;  they  soon 
leave  you  to  your  own  prudence,  and  advise  in  general  terms 
that  every  thing  should  be  done  to  preserve  the  limb.  You  are 
now  afloat,  and  must  abide  the  chance  of  time  and  circum- 
stances, for  after  a  day's  delay  the  limb  is  inflamed,  and  you 
never  call  a  second  consultation ;  it  is  too  late  (whatever  changes 
come  upon  the  limb)  to  perform  amputation  with  success ;  nor, 
indeed,  must  you  be  alarmed  at  the  appearance  of  gangrene, 
even  in  this  case,  where  gangrene  is  so  often  the  cause  of  death, 
for  the  force  with  which  the  parts  are  twisted,  or  the  bones  dri- 
ven through  the  skin,  occasions  an  extensive  ecchymosis,  which 
reaches  along  the  leg,  and  up  the  thigh  itself,so  that  the  whole  limb 
is  almost  black.  Nay,  you  must  not  be  alarmed  even  though  this 
blackness  turn  into  a  true  gangrene,  though  vesicles  rise,  the 


Of  Compound  Fracture  and  Luxation.  149 

part  lose  all  feeling,  and  the  patient  lie  in  a  degree  of  stupor ; 
tor  such  gangrene  is  often  but  superficial  ;  it  is  confined  to  the 
skin ;  it  is  limited  even  to  a  small  portion  oi  the  skin,  and  in 
eight  or  ten  days  small  sloughs  are  thrown  off,  the  suppuration 
is  established,  and  the  patient  revives.  Such  laceration  sel- 
dom or  never  adheres  immediately,  yet  is  otten  cured  by  sup- 
puration ;  and  sometimes,  when  pieces  ot  the  tibia  and  fibula 
have  been  separated  and  thrown  off,  when  the  astragalus  has 
been  fractured,  and  one  half  of  it  cut  out  by  the  surgeon,  the 
joint  has  healed  ;  nay,  it  has  even  happened  that  the  astragalus 
has  been  so  entirely  twisted  out  of  its  place,  that  it  has  morti- 
fied and  been  removed  by  the  surgeon,  and  yet  the  gangrene 
has  ceased,  the  suppuration  has  been  established,  granulations 
have  filled  up  the  great  hollow,  the  outward  wound  has  closed,  and 
(though  it  is  difficult  to  believe  so  surprising  a  fact)  the  bone 
has  been  so  far  regenerated,  that  the  patient  has  walked  firmly 
on  that  foot,  and  with  a  free  motion  of  the  ankle,  a  new  joint 
having  been  formed.  Yet  you  should  be  aware,  that  such  cures 
are  never  perfect ;  after  even  the  least  of  those  accidents  the 
joint  continues  long  weakly,  alwavs  rheumatic,  apt  to  swell 
with  the  slightest  fatigue,  and  requires  to  be  firmly  supported 
by  a  well-padded  buskin  laced  firmly  round  the  joint :  I  have 
seen  some  patients,  indeed,  who  did  not  absolutely  need  this, 
but  few  who  did  not  acknowledge  the  comfort,  security,  and 
strength  it  gave  them. 


(     150     ) 


DISCOURSE  XL 


ON  THE  ACCIDENTS  AND    DISEASES  OF  THE 
HIP-JOINT. 


SECTION    I. 


Diagnosis  of  the  various  accidents  and  diseases  of  the  Hip 
Joint. 

AN  distinguishing  the  various  affections  of  the  hip-joint,  we 
can  trust  nothing  to  the  opinions  of  the  older  surgeons,  so  en- 
tirely unacquainted  with  the  scrophulous  disease,  and  so  inac- 
curate in  their  distinctions  of  all  the  other  affections  of  the  joint. 
Nor  is  it  indeed  by  authority  and  the  facts  of  others  that  we 
should  be  guided  in  the  practice  of  our  profession,  but  rather 
by  reason,  by  our  knowledge  of  the  structure  of  the  parts,  and 
in  the  present  case,  by  observing  the  various  distortions  and 
shortenings  of  the  limb  ;J  for  it  will  be  found,  that  from  the  pe- 
culiar structure  of  the  hip-joint,  certain  accidents  will  produce 
invariable  appearances,  and  luxation,  fracture,  or  injury  of  the 
acetabulum,  will  give  infallible  signs  of  distinction  by  the  pecu- 
liar distortions  of  the  limb.  I  well  know  how  difficult  it  is  to 
remember  correctly  the  forms  of  any  internal  part,  and  how 
much  more  difficult  it  is  to  apply  such  anatomy  to  the  peculiar 
circumstances  of  each  case  ;  how  impossible  it  is  to  reason  up- 
on luxations  and  fractures  as  abstract  subjects,  without  some  sen- 
sible representation  of  the  facts  ;  it  is  for  this  reason  that  I  think 


Of  the  accidents  and  diseases  of  the  Hip- Joint,  151 

it  advisable  to  accompany  each  difficult  point  of  the  diagnosis 
with  a  simple  plan. 


The  first  plan  that  I  lay  before  you,  is  such  a  scheme  of  the 
hip-joint  as  will  explain  decidedly  the  effects  of  blows  or  falls  in 
various  directions,  (a)  Marks  the  deepest  part  of  the  socket 
which  entirely  receives  the  round  head  of  the  thigh-bone,  and 
upon  this  point  the  whole  weight  of  the  body  rests,  (b)  N^xt 
marks  the  head  of  the  thigh-bone  raised  and  turned  a  very  little 
out  of  its  acetabulum,  in  order  to  show  the  hollow  of  the  ace- 
tabulum and  the  root  of  the  round  ligament,  (c)  Marks  the 
round  ligament  which  arises  rather  from  the  lower  margin  of 
the  socket,  and  which  prevents  the  head  from  starting  out  of  the 
socket,  or  being  luxated  upwards  till  this  ligament  is  burst;  and 
indeed  it  would  seem  as  if  the  weight  of  the  body  were  in  some 
degree  supported  by  this  strong  ligament,  though  the  weight  is 
chiefly  balanced  upon  the  head  of  the  thigh-bone,  (d)  Marks 
that  deep  part  of  the  socket  where  the  mucous  ducts  and  fatty 
fimbriae  lie,  and  where  the  inside  lining  of  the  capsule  is  most 
peculiarly  delicate  ;  and  since  the  body  hangs  by  the  upper  part 
of  the  socket  on  the  top  of  the  thigh-bone,  this  delicate  appara- 
tus, lurking  in  a  small  dimple  at  the  lower  part  of  the  socket, 
escapes  all  dangerous  pressure,  and  is  but  gently  moved  as  the 
central  ligament  moves. 

With  the  plan  of  the  joint  thus  before  us,  nothing  is  more 


152         Of  the  accidents  and  diseases  of  the  Thigh-Bone. 

easy  than  to  judge,  with  almost  mathematical  precision,  of  the 
effects  or' each  particular  blow  or  twist.  1st.  In  the  perpendi- 
cular posture  of  the  bodv,  when  the  pelvis  rests  fairly  on  the 
head  of  the  thigh-bone,  the  neck  of  the  thigh-bone  bears  its  full 
share  of  the  weight  ;  and  in  falling  from  a  height  upon  the  feet, 
or  in  dropping  from  a  window,  or  in  falling  with  force  upon 
one  knee,  or  in  taking  a  high  and  dangerous  leap,  the  whole 
weight  ol  the  bodv  strikes  upon  the  head  ol  the  thigh-bone  in  a 
direction  transverse  to  that  of  the  neck.  The  resistance  of  the 
ligament  from  below,  and  the  deepness  of  the  socket  above, 
prevent  luxation  upwards,  and  the  neck  of  the  bone  breaks 
across.  The  direction  of  such  a  shock  is  indicated  by  the  dot- 
ted line  (l.)  A  blow  in  this  direction,  then,  may  fracture  the 
neck  of  the  thigh-bone,  or  may  so  bruise  the  socket,  as  to  pro- 
duce disease,  but  can  never  hurt  the  lubricating  apparatus, 
which  is  safely  lodged  at  (d),  where  there  would  in  that  case  be 
no  pressure. 

2d.  A  fall  in  which  the  foot  slips  inwards,  the  limb  is  twist- 
ed, and  the  body  falls  on  one  side  :  in  short,  when  the  thigh 
is  distorted  in  the  direction  marked  by  the  dotted  line  (2),  the 
head  of  the  bone  is  more  frequently  twisted  out  of  its  socket, 
and  luxated  upwards  ;  the  great  capsule  of  the  joint  is  burst  ; 
the  central  ligament  is  torn  up  by  its  roots  ;  and  the  head  of 
the  femur  is  lodged  on  the  back  of  the  haunch-bone,  or  in  the 
sciatic  notch. 

3d.  But  when  the  person  slips  his  foot,  so  that  the  inside  of 
the  ankle  slides  along  the  ground,  and  that  the  limb  is  twisted 
outwards  ;  or  when  having  a  heavy  burden  on  his  back,  he  falls, 
so  that  the  inside  of  the  knee  strikes  the  ground  ;  or  when,  as 
in  laying  a  sack  of  corn  from  his  back  upon  a  cart,  he  makes  one 
step  away  from  the  cart,  and  the  sack  falls  upon  his  extended 
leg,  so  as  to  twist  the  limb  outwards  ;  then  the  thigh-bone  comes 
into  the  direction  denoted  by  the  dotted  line  (3),  the  head  of 
the  thigh-bone  is  turned  downwards  towards  the  lower  part  of 
the  socket,  and  is  easily  luxated  in  that  direction,  becaust  there 
the  socket  is  imperfect,  its  border  is  low,  and  guarded  only  by 
a  ligament  (the  ligamentum  labri  cartaliginei)  while  the  central 
ligament  prevents  only  luxation  upwards,  because  its  root  arises 
netfr  this  lower  border  of  the  acetabulum. 

4th.  It  is  very  obvious,  that  when  the  thigh-bone  is  struck  in 
the  direction  of  the  dotted  line  (4)  by  a  fall  upon  the  trochanter, 
its  head  is  beaten  down  into  that  part  of  the  socket  where  the 
mucous  ducts  lie,  and  these  soft  parts  are  bruised,  whence 
comes  immediate  and  dreadful  pain,  high  inflammation  in  the 
joint,  and  sometimes  suppuration,  and  carries  off  the  acetabu- 
lum, followed  by  anchylosis. 


Of  the  accidents  and  diseases  of  the  Thigh-Bone.        153 

5th.  When  the  great  trochanter  is  struck  obliquely  from  a- 
bove  downwards  in  the  direction  of  the  dotted  line  (5),  any  of 
all  those  accidents  may  ensue,  for  the  head  of  the  bone  is  struck 
so  downwards  into  the  socket,  that  very  frequently  the  mucous 
ducts  are  injured;  or  being  struck  thus  obliquely,  the  head  of 
the  bone  may  be  luxated  downwards,  by  being  driven  over  the 
border  of  the  acetabulum  at  its  shallowest  part ;  or,  finally,  by 
being  struck  thus  obliquely,  the  neck  itself  may  be  broken. 

In  enumerating  these  consequences,  it  is  to  be  observed,  that 
the  effect  of  no  particular  blow  is  absolutely  limited,  while  yet 
it  may  in  general  terms  be  affirmed,  that  luxation  is  produced 
by  a  twist  of  the  limb;  fracture  of  the  neck  of  the  thigh-bone 
by  a  desperate  leap  or  fall  Irom  a  height ;  while  falls  in  which 
the  trochanter  strikes  the  ground,  though  they  do  sometimes* 
luxate  or  fracture  the  thigh-bone,  more  commonly  injure  the 
acetabulum  and  its  lubricating  apparatus.  It  must  be  matter 
of  wonder,  indeed,  how,  since  the  soft  parts  within  the  socket 
are  so  easily  injured,  they  ever  escape  disease  in  any  of  the 
common  accidents  of  the  joint :  but  it  is  to  be  observed,  first, 
That  the  bone  is  luxated  or  fractured  by  blows  or  twists,  which 
tend  rather  to  turn  the  head  out  of  the  acetabulum,  than  to 
drive  it  down  into  the  cavity.  Secondly,  That  the  mere  lace- 
ration of  an  internal  part,  as  of  the  central  ligament,  heals  very 
easily ;  for  in  every  case  of  luxation  it  must  be  torn,  and  yet 
no  disease  ensues.  Thirdly,  The  actual  fracture  or  luxation 
produces  no  disease,  because  that  peculiarity  of  constitution  is 
wanting,  which  produces  in  boys  the  most  dismal  consequences 
from  the  slightest  accidents,  not  in  this  joint  only,  but  in  all  the 
joints.  And,  lastly,  We  find,  that  even  when,  in  consequence 
of  inflammation  arising  from  mere  local  injury,  the  bones  do 
inflame  and  throw  out  callus,  it  is  a  healthy  inflammation,  like 
that  of  a  granulating  wound,  and  stops  spontaneously  as  soon 
as  the  callus  is  formed,  and  the  re-union  of  the  neck  of  the 
thigh-bone,  or  the  formation  of  the  new  socket,  completed.  The 
actual  condition  of  the  limb  may  be  ascertained  by  the  follow- 
ing marks : 

1st.  The  limb  being  sound,  or  but  slightly  hurt,  is  moveable, 
but  not  loose  ;  the  joint  moves  easily  and  smoothly  ;  you  can 
turn  the  thigh-bone  in  every  direction,  though  not  without  a 
degree  of  pain  proportioned  to  the  injury  ;  and  this  is  princi- 
pally to  be  noticed,  that  the  point  of  the  haunch-bone,  the  knee 
and  the  great  toe,  are  all  in  one  direct  line ;  or,  in  other  words, 
the  leg,  thigh  and  body,  all  lie  in  the  natural  direction,  with  re- 
gard to  each  other ;  and  the  limb  being  measured  with  its  fel- 
low, is  of  the  same  length,  and  answers  knee  to  knee,  ankle  to 
ankle,  and  toe  to  toe ;   for  though  the  patient  will  naturally  dis- 

U 


154         Of  the  accidents  and  diseases  of  the  Thigh-Bone, 

tort  the  leg  to  give  himself  ease  in  the  bruised  part,  yet  the  sur- 
geon can,  by  a  little  force,  make  the  limbs  even.     Figure  1st. 

2d.  When  the  thigh-bone  is  luxated,  the  limb  is  always  im- 
movably fixed  by  the  entireness  of  the  neck  of  the  bone,  and 
the  awkward  posture  in  which  the  head  lies  against  the  pelvis; 
and  when  the  thigh-bone  is  luxated  upwards,  we  have  the  fol- 
lowing decisive  marks  of  its  condition  :  The  head  and  neck  of 
the  thigh-bone  are  firmly  braced  down  against  the  back  of  the 
pelvis  by  the  surrounding  muscles,  whence  the  limb,  which  lies 
in  a  very  awkward  posture,  is  absolutely  immovable.  The 
head  of  the  bone  having  started  fairly  over  its  socket,  and  lying 
even  as  high  as  the  sciatic  notch,  that  is,  at  the  distance  of  three, 
or  rather  four  inches  from  its  natural  situation,  the  limb  is  very 
remarkably  shortened,  the  heel  of  the  luxated  limb  touching  the 
sound  one  a  little  higher  than  the  ankle.  Next  the  neck  of  the 
thigh-bone  being  entire,  and  the  head  of  the  bone  looking  back- 
wards towards  the  sciatic  notch,  the  whole  limb  is  singularly 
distorted,  the  toe  is  turned  inwards,  or  rather  backwards,  and 
the  knee  of  the  luxated  limb  falls  in  behind  the  thigh  of  the 
sound  one,  and  in  this  awkward  posture  the  limb  is  so  im- 
movably fixed,  that  when  you  attempt  to  turn  the  thigh-bone, 
you  give  great  pain ;  in  the  moment  of  the  attempt,  you  are  sen- 
sible of  insuperable  resistance ;  indeed,  if  you  could  turn  the 
thigh-bone,  you  would  reduce  it. 

Now,  when  the  limb  is  thus  luxated  upwards,  if  you  lay  your 
patient  on  his  belly,  you  will  find  the  leg  half  bent,  and  stand- 
ing up  at  right  angles  with  the  thigh ;  and  taking  the  leg  in 
your  .left  hand,  and  working  it  like  a  rudder,  backwards  and 
forwards,  laying  your  other  hand  at  the  same  time  flat  over  the 
haunch,  you  will  be  sensible,  every  time  the  thigh-bone  is  turn- 
ed, of  the  ball  or  head  of  it  turning  under  your  hand  ;  and  when 
you  persist  in  turning  it  very  largely  and  rapidly,  you  will  be 
very  sensible  of  the  head  and  neck  of  the  bone  clucking  against 
the  haunch-bone.  But  of  all  the  marks,  none  is  more  particu- 
lar than  this,  that  the  great  trochanter  rises  very  high,  the  pro- 
minence which  we  call  the  haunch,  seems  to  be  transferred  ve- 
ry high  up  upon  the  hip,  the  thigh  is  remarkably  shortened  and 
flattened,  and  when  you  first  begin  to  roll  the  thigh-bone,  and 
to  feel  the  joint,  you  would  be  apt  to  mistake  the  trochanter  for 
the  head  of  the  bone,  and  the  clucking  noise  of  the  luxated  bone 
for  the  grating  of  a  fractured  one.     Figure  2d. 

3d.  When  the  thigh-bone  is  luxated  downwards,  the  bursal 
and  central  ligaments  are  lacerated,  the  obturator  muscle  which 
fills  the  thyroid  hole,  is  in  part  torn  up  from  its  origin,  and  the 
head  of  the  bone  is  lodged  in  its  place  ;  the  turning  or  rotation 
of  the  thigh-bone  is  in  this  luxation  also  entirely  prevented  by 


P.  Id 4. 


etplainid .Putit   ld'-f 


Fiii  I  j\  ulural .  txf>  lain  id. 
Ptft.  ISi 


1 1  j  J  L  luiabtl .  JwnivjTili. 
tXflalmd  f*j 


[Jrn-nwirJs  an  J  IK 
tre  tunxtd  eat 


Skttch   fcr  tfi*  D  laqno^i-sof-Luxatienr 


■/£*//,'. 


F.JC/rrty.tfr, 


Of  the  accidents  and  diseases  of  the  Thigh- Bone.        153 

the  awkward  posture  of  the  neck  ;  the  head  of  the  hone  looks 
forwards,  or  rather  upwards,  and  the  limb  is  as  much  fixed  as 
when  luxated  upwards. 

All  the  peculiarities  of  the  distortion  first  described,  are  re- 
versed in  this  luxation  ;  the  head  of  the  bone  is  now  lodged  in 
the  thyroid  hole,  a  part  of  the  pelvis  so  much  lower  than  its  na- 
tural socket,  that  the  leg  is  lengthened  fully  three  inches.  The 
head  ot  the  bone  in  this  luxation  looks  forwards  and  upwards, 
so  that  the  toe,  which  was  turned  inwards  in  the  luxation  last 
described,  is  turned  outwards  in  this ;  and  the  head  being  now 
turned  forwards,  the  knee,  which  in  the  upward  luxation  lies 
under  the  sound  knee,  is  in  this  turned  remarkably  outwards, 
while  the  whole  limb  is  kept  in  a  very  remarkable  manner  strad- 
dling away  from  the  body.  In  the  luxation  upwards,  the  head 
of  the  bone  is  less  distinctly  felt,  because  the  trochanter  is  apt 
to  be  mistaken  for  it,  the  head  and  neck  l)ing  deep  under  the 
glutaei  muscles  ;  whereas  in  this  luxation,  the  head  of  the  bone 
is  felt  rolling  very  distinctly  and  superficially  in  the  groin,  very 
nearly  in  the  place  of  the  venereal  bubo,  for  at  this  point  the 
joint  of  the  hip  is  not  covered  with  large  muscles,  such  as  the 
Glutaei,  but  with  one  thin  and  flat  muscle,  the  Pectineus,  and 
the  joint  is  so  near  the  surface  here,  that  the  suppuration  in  the 
hip-joint  disease  usually  bursts  first  in  the  groin.     Figure  3d. 

4th.  The  peculiar  signs  of  fracture  of  the  neck  of  the  thigh- 
bone, are  not  less  decisive.  The  moment  the  neck  of  the  thigh- 
bone is  broken,  the  bone  is  retracted  by  the  power  of  its  mus- 
cles; it  is  turned  somewhat  round  by  the  rotatory  muscles  (the 
Obtur.  Internus.  quad.  Femoris,  &c.)  operating  upon  the  shaft 
of  the  bone  ;  and  while  the  head  and  neck  ot  the  bone  remain 
in  the  socket,  the  broken  part  of  the  bone  at  the  root  of  the  tro- 
chanters mounts  upwards.  The  following  signs  then  must  fol- 
low those  peculiarities  in  the  posture  of  the  bone.  First,  the 
moment  the  neck  of  the  thigh-bone  is  broken,  the  shaft  of  the 
bone  is  so  retracted  by  the  power  of  its  muscles,  that  you  would 
imagine  the  bone  to  be  luxated  upwards  ;  secondlv,  observing 
next  the  posture  of  the  leg,  you  find  that  the  toe  is  not  turned 
inwards,  nor  the  knee  of  the  hurt  limb  bent  in  under  that  ol  the 
sound  one,  it  is  turned  outwards,  but  not  in  that  fixed,  awkward, 
and  straddling  posture,  which  indicates  luxation  downwards. 
Thirdly,  you  next  begin  to  turn  the  limb  and  to  hearken  for 
crepitation  ;  but  you  will  remember  that  this  fracture  is  distinct 
from  all  others,  in  having  no  crepitation,  for  the  ends  of  the 
broken  bone  are  not  opposed  to  each  other  (as  where  a  bone  is 
broken  across  its  middle)  but  the  broken  neck  of  the  bone  re- 
mains in  the  acetabulum,  while  the  part  (i.  e.  the  root  of  the 
trochanters)  where  the  neck  of  the  bone  was  broken  away  from 


156        Of  the  accidents  and  diseases  of  the  Thigh-Bone. 


the  shaft  is  so  retracted,  that  the  fractured  parts  are  never  op- 
posed to  each  other,  unless  indeed  in  the  moment  of  extending 
the  limb  with  the  design  oi  setting  the  fracture,  lor  then  the 
limb  being  drawn  out  nearly  to  its  natural  length,  the  fractured 
parts  come  to  be  opposite  to  each  other,  and  the  crepitation  is 
distinguished.  Fourthly,  It  is  to  be  observed,  thai  the  limb 
cannot  be  fixed  and  embarrassed  by  the  neck  of  the  thigh-bone, 
as  in  luxation  ;  the  connexion  betwixt  the  head  and  shaft  of  the 
bone  is  destroyed  ;  the  limb  is  not  only  free,  but  absolutely  loose  ; 
the  natural  thigh-bone  moves  easily,  but  the  broken  thigh-bone 
turns  loosely,  as  far  as  a  bone  can  turn  loosely  which  is  encum- 
bered with  such  a  mass  of  muscles  lying  about  it. 

This  also  is  very  particular  ;  it  turns  vertically  like  a  spindle. 
If  you  take  in  your  hand  a  sound  limb  with  the  design  of  turn- 
ing it,  and  lay  the  palm  of  your  hand  over  the  trochanter,  you 
will  be  sensible  that  the  bone  moves  slowly  and  steadily,  be- 
cause is  is  connected  with  its  neck.  The  head  of  the  bone  is 
the  centre  of  the  motion,  the  trochanter  is  at  the  distance  of 
three  inches  from  that  centre,  and  moves  in  large  circles,  of 
which    the  neck  of  the 

thigh-bone  J^NKmB^5^  1S    tne   ra" 

shaftisbro-      \ — ■  mpE^    Jm\  <-      ffahapL     _J       ken     away 

shaft  of  the        Hpl.   jf  l^^l^ildlllSil)     Done   is  it- 

self the  cen-     ^^     *V1L  ^^^.    ^5r  H ^  J     tre  °^  m0~ 

of     course        ^^.    |T  j|R         j  ^Mr      J      turns  verti- 

cally   in  its  ^.  .      •  lSjL      ]     Jiii      W       place  with- 

out making  »|     \  Mp    /     It       (J         any    circle. 

neck  of  the  '  bone  thenis 

easily  distinguished  from  luxation,  by  the  ease  with  which  the 
limb  is  turned,  by  the  thigh-bone  turning  vertically  upon  its 
axis,  by  the  leg  being  much  shortened,  easily  lengthened  by  ex- 
tending it,  but  very  difficultly  retained.  But  though  I  affirm 
that  the  thigh-bone  is  easily  turned  and  moved  in  various  di- 
rections, I  mean  so  only  in  reference  to  the  mechanical  resist- 
ance, for  it  is  not  moved  without  dreadiul  pain  ;  the  ragged 
trochanters,  and  broken  part  of  the  bone,  are  lodged  among  the 
soft  parts,  and  every  time  you  try  to  draw  the  leg  outwards,  the 
patient  suffers  dreadful  pa;,i  from  the  pressure  of  the  broken 
part  of  tht  femur  against  the  lacerated  parts  which  lie  on  the 
back  of  the  haunch-bone ;  thence  it  is,  that  the  patient  is  no 


Of  the  accidents  and  diseases  of  the  Thigh-Bone.        157 

sooner  laid  in  bed  than  he  inclines  the  knee  inwards,  and  dis- 
torts the  limb,  in  order  to  raise  the  broken  end  of  the  bone,  and 
prevent  it  pressing  against  the  lacerated  flesh. 

This  last  observation  reminds  me  of  the  necessity  of  explain- 
ing two  doubtful  points  in  the  diagnosis;  first,  it  is  not  certain 
that  the  toe  is  always  turned  outwards ;  secondly,  it  is  not  cer- 
tain that  the  limb  is  always  immediately  shortened.  You  may 
have  observed  that  Paraeus  describes  the  toe  as  turned  inwards, 
"  the  limb  shortened,  and  the  foot  turned  inwards  "  Petit 
also,  in  his  Maladies  des  Os,  mentions,  that  being  called 
to  a  patient  under  the  care  of  a  surgeon  who  had  not  read 
Paraeus,  and  who  mistook  the  nature  of  the  injury,  u  he 
found,  upon  undoing  the  bandages,  the  great  trochanter 
four  inches  higher  than  its  natural  situation,  and  the  toe  and 
the  knee  turned  inwards."  But  it  should  be  remembered, 
that  the  ease  with  which  the  thigh-bone  turns  vertically,  or  in 
other  words,  the  ease  with  which  we  turn  the  toe  outwards  or 
inwards  at  pleasure,  is  among  the  most  decisive  marks  of  this 
kind  of  fracture  ;  that  though  the  toe  is  naturally  turned  out- 
wards by  the  action  of  the  rotatory  muscles,  yet  we  can  easily 
turn  it  in  ;  this  implies  that  the  patient  himself  can  turn  it  in. 
He  often  does  turn  it  in  that  he  may  lie  with  greater  ease  ;  and 
accordingly  you  will  often  find  the  patient  King  with  the  toe 
turned  in,  and  the  knee  of  the  hurt  limb  turned  under  the  knee 
of  the  sound  one,  for  in  this  posture  the  fractured  part  ol  the 
bone  is  lifed  up  from  the  lacerated  flesh.  In  short,  there  are 
two  postures  of  the  limb  :  first,  That  which  it  takes  while  the 
parts  are  insensible  immediately  after  the  accident  ;  secondly, 
That  which  it  is  instinctively  put  into  for  ease  after  the  patient 
is  laid  in  bed.  But  though  the  posture  of  the  limb  comes  thus 
to  be  nearly  that  of  a  luxated  thigh,  viz.  the  limb  shortened,  the 
toe  turned  in,  the  one  knee  falling  under  the  other,  yet  still  1  pic- 
ture is  easily  distinguished  from  luxation  by  the  mobility  ol  the 
limb. 

Secondly,  There  is  one  point  more  in  which  there  is  a  de- 
gree of  uncertainty,  for  the  most  decisive  s\  mptom  of  all  is 
sometimes  wanting,  I  mean  the  shortening  of  the  limb  :  The 
shortening  of  the  limb  in  fracture  of  the  neck  of  the  thigh  bone, 
is  not,  as  in  luxation,  the  unavoidable  effect  of  the  posture  of  the 
bone  ;  it  is  an  accidental  consequence  of  the  contraction  of  the 
muscles,  and  sometimes  these  are  so  benumbed  by  the  injury, 
or  so  inactive  from  some  other  cause,  that  they  do  not  pull  up 
the  thigh-bone.  Even  though  we  were  less  able  to  explain  the 
fact,  we  are  not  less  constrained  to  receive  it,  it  stands  upon 
record.  Sabattier  has,  in  consultation  with  Louis,  Foubert,  and 
Goursoud,  seen  on  several  occasions  the  neck  oi  the  thigh-bone 


158  The  Diagnosis  Recapitulated. 

broken,  the  limb  remaining  of  its  usual  length,  and  the  retrac- 
tion happening  suddenly,  from  the  patient  being  turned  rather 
rudely  in  bed  by  the  helper  of  the  hospital.  Sometimes  this 
retraction  has  taken  place  on  the  fourth  or  fifth,  sometimes  not 
till  the  twenty-third  day  after  the  accident.* 

The  causes  then  of  luxation  and  of  fracture,  are  as  different  as 
the  causes  of  hydrocele  and  aneurism  j  fracture  always,  or 
almost  always,  arising  from  a  fall,  a  blow,  or  a  violent  strain 
of  the  muscles  ;  while  luxation  as  certainly  arises  lrom  a  sud- 
den twist  of  the  joint,  when  the  weight  of  the  body,  in  some 
awkward  posture,  is  thrown  entirely  upon  the  joint,  and  the 
limb  is  so  far  out  of  its  natural  direction,  as  to  be  entirely  be- 
yond the  power  of  its  own  muscles. 


SECTION    II. 

Of  Luxation. 

In  what  degree  the  ligaments  of  the  joint  will  extend  when 
they  are  gradually  dilated  by  a  collection  of  serum  within,  we 
need  not  at  present  dispute.  Unquestionably  they  are  capable 
of  distention,  of  almost  incredible  distention  ;  but  that  the  head 
of  the  thigh-bone  should  be  all  at  once  displaced  by  a  twist, 
forced  clear  out  of  its  socket  over  the  back  of  the  haunch  bone, 
and  lodged  in  an  instant  at  the  distance  of  four  inches  from  its 
natural  place,  without  laceration  of  its  ligaments,  with  its  liga- 
ments merely  dilated,  is  impossible.  There  is,  indeed,  no  fact 
of  which  we  are  better  assured  than  this,  that  when  the  head  of 
the  bone  is  twisted  out  of  its  socket,  there  is  no  dilatation  of  the 
capsule,  there  is  no  subluxation,  as  it  is  called  ;  the  head  of  the 
bone  never  stands  upon  the  edge  of  the  socket,  for  then  it  would 
immediately  fall  back  into  its  place  ;  but  the  capsular  ligament 
is  burst,  the  central  ligament  is  torn  up  from  its  root,  the  mus- 
cles which  lie  in  the  thyroid  hole,  or  on  the  back  of  the  haunch 
bone,  are  displaced,  to  make  way  for  the  head  of  the  thigh-bone, 
which  lies  betwixt  the  naked  haunch  bone  and  those  lacerated 
muscles,  and  there  it  remains,  undergoing  changes  which  are  of 
the  most  interesting  nature. 

Of  Luxation  of  the  Femur  downwards. 

1st,  While  the  head  of  the  bone  lies  thus  among  the  lacera- 

*   When  the  fracture  takes  phce  within  the  capfular  ligament,  if  this  is  not 
torn,  its  ftrength  prevents  this  effect  from  immediately  taking  place.       S 


Of  Luxation  of  the  Femur  downwards.  159 

ted  parts,  the  slightest  motion  occasions  excruciating  pain,  and 
as  the  slightest  motion  prevents  adhesion,  the  head  of  the  bone 
continues  long  reducible.  When  the  bone  is  first  driven  out  of 
its  socket,  the  patient  hears  the  crash  of  the  lacerating  ligaments, 
and  when  a  recent  luxation  is  reduced,  the  head  of  the  bone 
being  distorted  in  respect  to  its  posture,  and  very  firmly  braced 
down  by  the  contorted  muscles,  goes  home  into  its  place  with  a 
violence  proportioned  to  the  tension  of  the  muscles  with  a  loud 
snap ;  but  when  an  old  luxation  is  reduced,  the  reduction,  which 
is  opposed  by  the  strong  adhesions,  requires  a  lorce  equal  to 
that  by  which  the  bone  was  luxated,  if  not  greater ;  and  in  the 
instant  in  which  the  adhesions  give  way  to  that  force,  the  patient 
and  the  surgeon  both  feel  the  same  crash  of  laceration  which 
accompanied  the  first  displacement  of  the  bone  ;  it  often  sounds 
as  if  the  neck  of  the  bone  were  broken  by  the  violence.  This 
is  the  sign  of  the  luxation  being  reduced,  and  the  surgeon 
should  be  aware  of  it ;  for  I  have  often  been  sensible  of  this 
crashing  and  laceration  among  the  ligaments,  which  announces 
the  yielding  of  the  dislocated  bone  ;  but  as  the  head  of  the  bone 
does  not,  in  such  old  luxations,  go  home  with  a  sudden  nor  dis- 
tinct snap,  the  extension  has,  to  my  certain  knowledge,  been  of- 
ten continued,  even  after  the  bone  has  been  reduced,  and  that 
with  a  degree  of  violence  almost  sufficient  to  tear  the  limb  from, 
the  body.  Observe  this  in  your  future  practice,  and  you  will 
find  that  I  am  not  incorrect ;  and  if  what  I  have  alleged  be 
true,  the  vis  percussionis  (far  from  being  a  subject  for  thought- 
less jokes)  is  perhaps  absolutely  necessary  to  the  reduction  of 
old  and  confirmed  luxations. 

2d,  Though  the  capsule  so  entirely  surrounds  the  joint,  that 
it  can  in  no  case  escape  sudden  laceration  when  the  head  is  dri- 
ven from  its  socket,  yet  the  muscles,  which  are  small,  which 
turn  round  the  joint  with  small  tendons,  and  are  implanted 
about  the  roots  of  the  trochanters,  and  are  but  slightly  connect- 
ed with  the  capsule  are  very  seldom  torn.  The  head  of  the 
bone  bursts  through  the  capsule,  and  tears  it  in  a  very  irregular 
way ;  but  it  passes  out  betwixt  the  tendons  of  the  muscles, 
without  tearing  them  ;  therefore  it  happens,  that  as  soon  as  the 
bone  is  reduced,  as  soon  as  the  head  of  the  thigh-bone  is  drawn 
out  from  among  the  lacerated  parts,  and  again  lodged  in  its 
proper  socket,  all  pain  ceases,  the  patient  exclaims  that  he  is  re- 
lieved ;  and  as  the  muscles  preserve  their  attachments  to  the 
bone,  and  are  now  restored  to  their  offices,  he  moves  the  joint 
as  easily,  and  walks  upon  it  as  firmly  as  before,  and  returns  to 
his  business  or  pleasures  sometimes  without  one  day's  interrup- 
tion ;  and  though  the  capsule  is  completely  lacerated,  yet  as  it  is 
connected  on  its  external  surface  with  the  surrounding  part<=. 


160  Of  Luxation  of  the  Femur  downwards. 

and  these  also  are  injured,  they  swell,  and  the  surrounding  parts 
being  close,  the  edges  of  the  lacerated  capsule  are  re gularly  op- 
posed to  each  other,  and  the  entireness  of  the  capsule  is  soon 
and  easily  restored  :  rest  is  not  necessary  to  these  adhesions. 

3d,  When  the  head  of  the  bone  remains  unreduced,  new  and 
important  changes  take  place  on  the  head  of  the  bone  itself,  and 
on  the  part  against  which  it  rests.  When  the  thigh-bone  is 
luxated  downwards,  it  displaces  in  some  degree  the  obturator 
muscle,  and  rests  in  the  hollow  of  the  thyroid  hole  covered  by 
the  lacerated  muscle,  and  pressing  against  the  bone,  and  there 
it  lies  braced  down  by  the  distortion  of  the  other  muscles. 
The  surgeon  cannot  turn  it  in  examining  the  parts,  except  in  a 
very  slight  degree,  so  firmly  is  it  embraced  by  the  muscles  ;  and 
besides,  the  patient  is  careful  to  prevent  even  the  slightest  mo- 
tion, for  motion  is  productive  of  excruciating  pain.  He  lies 
immovable  for  some  weeks!  the  hollow  in  which  the  head  of 
the  thigh-bone  lies,  is  lacerated  and  raw ;  the  parts  surrounding 
the  neck  of  the  thigh-bone  are  also  lacerated,  which  parts  mu- 
tually adhere  so  as  to  form  a  new  and  perfect  capsule.  The 
head  of  the  bone  resting  in  the  thyroid  hole,  as  in  a  socket, 
comes  at  last  to  move  in  it  with  a  degree  of  ease ;  and  the  pel- 
vis, resting  thus  fairly  upon  the  head  of  the  thigh-bone,  is  stea- 
dily supported  ;  and  though  the  leg  is  much  lengthened  in  this 
luxation,  so  as  to  make  the  patient  halt  towards  the  sound  side, 
yet  the  limb  thus  luxated  downwards  bears  up  the  body  firmly. 

This  is  one  striking  peculiarity  of  the  luxation  downwards 
into  the  thyroid  hole.  But  still  farther  changes  take  place,  very 
slowly  indeed,  for  the  changes  I  mean  now  to  speak  of  affect  the 
bones  themselves.  It  seems  to  be  after  the  thigh-bone  is  fixed 
in  its  new  situation,  and  after  the  continuity  of  vessels  is  restor- 
ed, that  the  bones  begin  to  change  their  form.  The  soft  parts 
connected  with  this  surface  of  the  pelvis  are  all  swelled,  vascu- 
lar, inflamed,  and  in  the  condition  of  the  periosteum  and  soft 
parts  surrounding  a  fractured  bone.  This  mass  of  active  ves- 
sels connected  directly  with  the  vessels  of  the  bone  itself,  draws 
them  also  into  an  active  state.  A  secretion  of  bony  matter  be- 
gins, the  new  bone  is  deposited  in  the  now  inflamed  capsule  in 
the  surrounding  cellular  substance,  and  among  the  lamellae  of 
the  obturator  ligament,  against  which  the  head  of  the  bone  rests, 
and  which  is  of  course  irritated  and  inflamed.  The  thyroid 
hole  comes  in  time  to  be  filled  up  with  ossification,  so  as  to 
make  a  bottom  for  the  new  socket.  The  edges  of  the  thyroid 
hole  sprout  out  so  as  to  form  lips  or  edges  for  the  socket ;  and 
these  edges  sometimes  are  so  deep  as  to  surround  entirely  the 
neck  of  the  thigh-bone,  and  to  form  a  complete  box  of  bone,  in 
which  the  head  of  the  thigh-bone  is  so  enclosed,  that  though 


Luxation  of  the  Thigh-Bone  upwards. 


161 


perfectly  moveable,  the  head  cannot  be  disengaged  from  its  new 
socket. 

Nor  does  even  the  thigh-bone  itself  always  retain  its  original 
shape  ;  while  excitement  enlarges  a  bone,  pressure,  on  the  con- 
trary, prevents  its  growing  in  a  young  person,  or  even  lessens  it 
when  full  grown.  The  thigh-bone,  when  thus  luxated,  bears 
the  weight  of  the  body  in  a  new  direction,  the  obliquity  of  the 
neck  is  lost,  the  head  of  the  bone  now  receives  the  pressure  in 
one  direction  onlv,  whence  the  head  of  the  bone  is  flattened, 
and  the  neck  is  in  time  depressed,  loses  all  its  obliquity,  is  short- 
ened, and  stands  out  at  right  angles  from  the  shaft  of  the  bone  ; 
and  as  the  shoulders  and  neck  of  the  bone  now  press  against  the 
lower  part  of  the  empty  socket,  that  part  yields  to  the  pressure, 
the  lower  edge  of  the  socket  is  depressed  inwards,  and  the  ge- 


'  ■  ' 


1  have  given  in  this  drawing  one  of  the  moll  extraordinary  facls  in  this  depart- 
ment of  pathology.  I  have  reprefentcd  here  a  thigh-bone  which  was  luxated 
downwards  and  backwards  into  the  fciatic  notch,  and  there  formed  for  itfelf  a  new 
Pocket,  where, though  entirely  enclofi  d  in  the  b>'x,  as  the  French  academicians  have 
chofen  to  call  it,  it  was  11:11  moveable.  One  thing  is  very  curious,  that  in  this 
new  fockct  there  is  a  certain  opening  feparatcd  from  the  red  by  a  thin  parti 
bone,  through  which  thi  nply  the  joint. 

X 


162  Luxation  of  the  Thigh- Bone  upwards. 

neral  cavity  of  the  socket,  now   forsaken  by  the  head  of  the 
bone,  is  almost  filled  up. 

Luxation  of  the  Thigh-Bone  upwards. 

4.  When  the  thigh-bone  is  luxated  upwards  and  remains  un- 
reduced, the  new  joint  and  all  its  apparatus  is  less  perlect,  and 
the  patient  continues  Very  lame.  I  he  head  of  the  thigh-bone 
being  now  lodg.-d  on  tht  back  ol  the  haunch  bone,  upon  a  flat 
and  gliding  surface,  obtains  a  fixed  place  with  great  difficulty  ; 
there  is  no  hollow  like  the  thyroid  hole  to  receive  it  ;  there  is 
not  here,  as  in  the  luxation  downwards,  a  variety  of  surface  and 
gnat  extent  of  bone  wrought  upon  by  the  head  of  the  femur  ; 
the  generation  of  bone  is  very  sparing ;  an  accidental  socket 
is  indeed  formed,  but  shallow,  smooth,  irregular,  not  deep, 
not  sufficient  to  receive  or  lodge  the  head  of  the  thigh-bone  j 
it  is  rather  a  dimple  than  a  solid  socket,  and  looks  merely  as 
if  the  haunch  bone  being  softened  had  been  slightly  impressed 
by  the  head  of  the  thigh-bone.  How  does  the  patient  walk 
then  in  this  case  \  Very  miserably  ;  his  thigh-bone  rather  lies 
upon  the  side  of  th  haunch  bone  than  under  it,  so  as  to  sup- 
port the  weight  of  the  body ;  the  weight  of  the  body  is  sus- 
pended upon  the  head  of  the  thigh-bone  by  the  strong  liga- 
ments that  are  generated  out  of  the  lacerated  capsule,  aided 
by  that  cellular  substance  which  connects  the  lower  surface  of 
the  glutei  muscles  with  the  bone.  The  dislocated  leg  is  remark- 
abl>  shortened,  and  when  the  patient  rises  on  the  sound  limb  to 
make  a  new  step,  the  luxated  bone  hangs  in  air  ;  and  when  the 
dislocated  limb  is  in  its  turn  put  to  the  ground,  the  whole  weight 
of  the  body  falls  heavily  upon  those  thickened  ligaments  ;  at  eve- 
ry step  the  patient  twists  the  body,  and  turns  the  pelvis  so  as  to 
throw  the  haunch  bone  flat  upon  the  head  of  the  thigh-bone, 
and  this  inclination  of  the  trunk,  together  with  the  shortness  of 
the  limb,  distorts  the  whole  body  ;  and  in  this  case  the  weight 
falls  so  heavily  upon  the  neck  of  the  thigh-bone,  that  it  gives  way 
under  it.  The  head  of  the  thigh  bone  is  flattened,  the  neck  is 
shortened,  it  is  also  bent  downwards,  as  if  it  had  given  way,  as 
if  it  had  slided  a  little  lower  along  the  shaft  of  the  bone.  When 
we  look  at  the  thigh-bone  which  has  been  long  luxated,  we 
should  at  first  believe  that  it  had  been  actually  fractured,  and 
the  neck  shortened  ;  but  upon  examining  the  neck,  we  find  no 
mark  of  fracture,  while  we  easily  distinguish  many  marks  of  the 
long  continued  pressure,  for  the  whole  of  the  upper  part  of  the 
thigh-bone,  even  to  the  trochanters,  is  extenuated,  the  neck  is 
somewhat  extenuated  and  bent  down,  the  head  also  is  smaller 
than  that  of  the  sound  thigh-bone,  and  on  the  top  of  the  globu- 


Luxation  of  the  Thigh- Bone  upwards.  163 

iar  head  of  the  thigh-bone  is  a  depression'  or  flatness,  indicating 
the  place  where  the  back  of  the  haunch  bone  rested  upon  it. 

In  such  a  luxation  remaining  unreduced,  the  weight  of  the 
trunk  is  ill  supported,  the  motions  of  the  joint  very  imperfect, 
the  limb  remarkably  shortened,  and  wasted  in  some  degree, 
while  the  whole  person  is  distorted  and  bent  towards  the  lame 
side.  Though  such  luxation  happen  during  infancy,  the  person 
never  recovers,  but  continues  lame,  pained,  unable  to  ride  on 
horseback,  easily  fatigued,  equally  unfit  for  business  or  pleasure, 
and  reminded  of  his  misfortune  every  moment  of  his  life. 

SECTION    III. 

Pathology  of  the  diseased  Acetabulum,  or  Affection  of  the  soft 
parts  xvitlun  the  Hip- Joint. 

The  disease  I  am  now  to  describe  proceeds  from  a  fall  up- 
on the  haunch  (as  when  the  foot  slips  upon  ice,  &c.)  in  which 
the  trochanter  being  directly  struck,  the  head  of  the  thigh-bone 
is  beaten  down  into  the  socket,  the  round  Ligament,  which  oc- 
cupies the  bottom,  and  the  mucous  fnngt  s,  which  are  contain- 
ed rather  in  the  lower  part  oi  the  socket,  are  violently  bruised, 
whence  arises  immrd'ate  and  very  terrible  pain,  continuing  for 
manv  months.  The  torturt  is  excruciating,  the  pati<  nt  cannot 
be  turned,  nor  even  moved,  in  the  most  gmtle  manner  in  bed  ; 
after,  perhaps,  a  year's  suffeting,  he  beginb  to  move  about  up- 
on crutches,  entirely  lame.* 

This  accident  is  clearly  distinguished  from  fracture,  because 
there  is  neither  crepitation  nor  shortening  of  the  limb  ;  from 
luxation,  because  the  limb  turns  easilv  ;  and  from  those  and  all 
other  affections  by  this,  that  though  it  turns  easily,  and  there  is 
no  mechanical  obstruction  to  motion,  the  patient  cannot  suffer 
it  to  be  turned,  every  motion  of  the  head  of  the  bone  rolling  a- 
gainst  the  injured  parts  ot  the  socket  producing  delirious  and 
frantic  outcries.  Sometimes  this  inflammation  of  the  joint  sub- 
sides, and  after  long  confinement  and  torture,  perhaps  after 
using  warm  baths,  frequenting  watering-places,  fomenting  and 
gradually  exercising  the  joint,  the  patient  recovers  the  use  of 
his  limb ;  but  much  more  frequently  he  continues  lame. 

It  is  not  difficult  to  imagine,  and  indeed  to  prove  by  dissec- 
tion, various  changes  by  which  the  joint  is  destroyed.  The 
first  effect  of  such  inflammation  and  insufferable  pain  is,  to  pro- 
duce a  trembling  solicitude  on  the  part  ot  the  patient  to  prevent 

*  It  does  not  always  happen  that  thefe  fymptoms  fupervene  immediately  after 
the  accident.  1  have  feveral  times  fetn  fome  days  elapfe  before  the  patient  com- 
plained of  pain,  or  was  perceptibly  lame.     S. 


164  Affection  of  the  Hip-Joint. 

the  slightest  metion  of  the  limb.  The  patient  lies  in  all  the 
filthiness  of  a  sick  bed,  will  not  permit  a  pillow  to  be  changed, 
or  a  sheet  to  be  rolled  under  him  ;  even  the  trembling  of  the 
floor,  when  people  walk  rudely,  increases  his  irritability,  if  not 
his  actual  torture.  This  is  almost  like  a  provision  of  Nature, 
for  motion  actually  does  harm,  excites  inflammation,  brings  the 
inflammation  forward  to  abscess  of  the  joint  and  caries  of  the 
bones,  and  prevents  anchylosis,  which  is  often  the  only  possible 
cure  :  the  presumptuous  interference  of  quacks  with  the  pro- 
cess of  Nature,  their  daring  to  twist  and  turn  such  a  limb,  under 
the  pretext  of  reducing  luxation,  has  actually  proved  fatal. 

The  stillness  of  the  patient,  and  the  uniform  posture  for  ma- 
ny months,  favours  all  those  changes  which  are  apt  to  take 
place  in  a  joint  thus  highly  inflamed.  Sometimes  the  inflam- 
mation stops  short  of  ulceration,  the  capsule,  tendons  and  mem- 
branes surrounding  the  joint,  are  merely  thickened  by  the  in- 
flammation, and  the  joint  remains  stiff,  rheumatic,  but  move- 
able, and,  as  far  as  pain  will  allow,  useful.  Sometimes,  and 
especially  in  younger  people,  the  inflammation  runs  high,  ab- 
scess forms,  and  after  repeated  paroxysms  of  inflammation  and 
most  excruciating  torture,  the  matter  bursts  out  at  the  haunch 
or  in  the  groin,  with  proportioned  relief  of  pain.  Often,  you 
may  suppose,  before  the  matter  thus  bursts  out,  the  bones  them- 
selves are  ulcerated,  the  capsule  is  destroyed,  the  head  of  the 
bone  is  extruded  from  the  acetabulum,  and  retracted  by  the 
force  of  its  muscles  upon  the  back  of  the  haunch-bone  ;  then 
the  leg  is  shortened  ;  and  this  is  what  the  ancients  called  Sub- 
luxation, the  French,  Luxation  Consecutif,  and  which  has  been 
by  almost  nil  surgeons  acknowledged  as  a  luxation  under  the 
title  of  Luxation  from  an  Internal  Cause.  Often  the  bones, 
thus  eroded,  become  carious,  and  not  unfrequently  hectic  en- 
sues, and  the  patient  dies. 

If,  escaping  all  those  dangers,  the  patient  live,  and  the  bones 
granulate,  they  unite  with  each  other ;  for  the  persevering  pos- 
ture of  the  patient  prevents  «the  process  of  ossification  being  dis- 
turbed, more  effectually  than  our  most  severe  and  curious 
bandages  could  do  ;  the  bones  unite  with  each  other  often  in 
the  most  awkward  direction,  the  thigh-bone  being  fixed  and 
united  with  the  pelvis  at  right  angles  in  respect  to  the  body. 

SECTION    IV. 

Of  the  scrophidous  Disease  of  Boys,  or  the  Disease  of  the  Boties 
rvhich  compose  the  Hip- Joint. 

The  scrophulous  disease  of  this  joint  is  peculiarly  frequent  in 


Affection  of  the  Hip- Joint.  165 

boys  from  five  to  eighteen  or  twenty  years  of  age,  and  is  of  that 
insidious  nature,  that  its  approach  is  hardly  observed  ;  the  dis- 
ease is  established  before  its  symptoms  are  noticed,  even  by  the 
most  affectionate  and  attentive  parents,  and  it  ends  in  total  ca- 
ries of  the  joint,  with  anchylosis  or  cohesion  of  the  diseased 
bones,  though  often,  from  the  suppurations  and  dreadful  pain, 
hectic  and  death  prevent  this  imperfect  cure.  The  bones,  and 
not  the  soft  parts,  are  the  seat  of  the  disease,  therefore  its  pro- 
gress is  very  slow  ;  the  pain  is  so  dull,  that  the  boy  walks  and 
runs  about  for  months  alter  the  disease  is  formed.  The  parents 
first  observe  an  awkwardness  and  trailing  of  the  affected  limb, 
as  if  it  were  weakly  ;  the  boy  complains  little,  except  of  weari- 
ness after  play,  and  of  that  numbness  and  stupor,  with  dull  and 
heavy  pain,  which  the  parents  mistake  for  growing  pains,  so 
frequent  in  boys. 

The  boy  now  begins  to  stand  always  on  the  sound  limb,  and 
in  such  a  posture,  that  the  parents  chide  him  for  awkward  ha- 
bits. Alter  sitting  a  little  while,  his  joint  stiffens  ;  when  he  re- 
turns to  play,  he  begins  to  leel  pain  ;  when  he  is  warmed  by 
exercise,  the  joint  moves  more  easily,  and  he  runs  his  race  with 
his  play-fellows  ;  but  when  his  bout  of  exercise  is  over,  he  falls 
again  into  a  state  of  languor.  The  limb  seems  weakly,  and  be- 
gins to  waste,  the  boy  loses  his  health  and  complexion,  from 
day  to  day  he  complains  more  and  more  of  pain,  till  at  last  he 
is  confined,  and  a  puffy  swelling  appears  about  the  joint. 

During  all  this  stage  ot  the  disease,  the  bone  is  swelling  and 
becoming  more  vascular,  the  lining  of  the  acetabulum,  and  the 
periosteum  covering  the  head  of  the  thigh-bone,  are  thickened 
in  common  with  the  bones  themselves,  which  are  now  swelled. 
The  head  of  the  thigh-bone  is  protruded  in  some  degree  from 
its  socket,  just  as  a  diseased  tooth  is  protruded  from  its  socket 
by  a  bag  of  suppuration  forming  under  its  fangs.  Still  the  dis- 
ease is  limited  to  the  bones  ;  there  is  not,  as  in  the  disease  aris- 
ing from  bruises  of  the  acetabulum,  excruciating  acute  pain  ; 
although  the  leg  be  remarkably  elongated,  so  as  to  straddle  a- 
way  from  the  body,  though  it  be  so  elongated  that  when  the 
boy  stands  on  the  diseased  leg,  the  toes  only  of  the  sound  one 
touch  the  ground,  yet  he  is  almost  without  pain,  and  walks  with 
a  degree  of  ease  :  exercise,  or  the  common  degree  of  motion, 
during  this  stage,  is  not  so  difficult  on  account  of  pain,  as  im- 
prudent, from  its  increasing  that  affection  of  the  bones  which 
unhappily  is  too  late  of  declaring  itself  by  acute  pain. 

But  at  last  the  stage  of  acute  pain  does  come  ;  the  boy  be- 
comes unable  to  move  ;  the  pain  becomes  very  acute  ;  the  soft 
parts  which  connect  the  bones  begin  to  partake  of  the  inflamma- 
tion ;  there  is  redness  now,  as  well  as  swelling,  round  the  haunch. 


166  Affection  of  the  Hip- Joint. 

The  pain  is  often,  though  not  always,  excruciating  ;  abscesses 
form  round  the  joint  ;  the  matter  bursts  out,  first  at  the  groin, 
then  at  the  hip  ;  as  the  abscesses  give  vent  to  the  matter,  the 
torture  is  in  some  degree  relieved,  as  one  sinus  or  ulcer  dries 
or  closes  up,  another  runs  more  plentifully,  or  new  abscesses 
form.  Then  the  cartilages  are  ulcerated,  the  matter  which  had 
distended  the  capsule  is  evacuated,  and  the  swelling  of  the  parts 
within  the  acetabulum,  which  had  in  some  degree  extruded  the 
head  of  the  bone  from  its  socket,  subsides,  the  head  of  the  bone 
falls  down  again  within  its  acetabulum ;  the  limb,  remarkably 
elongated  at  first,  is  shortened  in  this  second  or  suppurative 
stage  of  the  disease. 

The  cure  of  the  disease  is  now  to  be  looked  for,  or  the  pa- 
tient's death.  The  patient,  wasted  with  suppuration,  and  tor- 
tured night  and  day  with  excruciating  pain,  becomes  greatly  ex- 
tenuated ;  he  is  reduced  to  skin  and  bone  ;  he  is  pale,  and  ca- 
daverous in  the  face,  the  nose  is  pinched,  the  eyes  starting  from 
their  sockets,  and  the  face  altogether  shrunk  and  shrivelled  up 
with  discontent  and  pain.  Often,  the  suppuration  and  caries 
extending  aiong  the  bones,  the  whole  pelvis  is  affected,  the  dis- 
charge is  profuse,  and  the  child  dies  of  hectic  ;  but  sometimes 
the  matter  ceases  to  flow,  the  high  inflammation  subsides,  the 
bones  begin  to  granulate  within,  like  soft  parts,  (as  they  indeed 
are  in  the  boy  extremely  vascular)  and  by  perseverance  in  one 
uniform  posture,  the  bones  unite,  a  proper  anchylosis  is  formed, 
smaller  suppurations  are  occasionally  observed  and  opened,  till 
at  last  the  bones,  after  successive  fits  of  inflammation,  are  en- 
tirely united  with  each  other.  The  thigh-bone  is  generally  united 
witn  the  haunch-bone  at  an  angle  more  or  less  acute,  according 
to  the  posture  which  the  child  had  found  the  most  easy  ;  fre- 
quently it  is  found,  when  the  bov  begins  to  walk  with  his  crutch, 
that  the  thigh  protrudes  forwards  ;  sometimes  it  is  in  the  natu- 
ral direction  of  the  body  ;  but  even  then  the  limb  hangs  in  air, 
it  is  extenuated  by  want  of  exercise  and  by  disease  ;  the  dis- 
eased limb  has  been  stationary  in  its  growth  for  eighteen  months 
or  two  years,  while  the  other  limb,  and  the  rest  of  the  body, 
has  been  growing  ;  thence  the  affected  limb  is  always  shortened, 
and  often  useless. 

This  is  plainly  a  disease,  and  a  slow  disease  of  the  bones  ;  it 
is  a  disease  of  boys,  because  in  them  the  bones  are  but  form- 
ing ;  it  is  a  disease  of  scrophulous  boys,  because  in  that  state 
of  the  system  ossification  is  a  slow  and  imperfect  process  ;  it  is 
a  disease  most  frequent  in  the  bones  with  great  joints,  because 
they  are  large,  and  are,  till  the  twentieth  year,  very  imperfectly 
formed. 

In  this  disease  the  pains  are  dull,  because  the  bone  is  insensi- 


Affection  of  the  Hip-Joint.  167 

ble  ;  slow,  because  the  firm  system  of  a  bone  does  not  easily 
enter  into  disease  ;  the  elongation  or  the  joint  is  a  sure  sign 
that  the  disease  is  established,  and  the  head  of  the  bone,  the 
socket  and  the  soft  parts  beginning  to  swell,  the  excruciating 
pain  demonstrates  that  the  solt  parts  are  fully  inflamed  and  ul- 
cerated, and  that  to  the  original  disease  ol  the  bone  is  now  add- 
ed a  disease  of  the  surfaces,  such  as  takes  place  after  the  bruise 
of  the  acetabulum  ;  and  finally,  the  shortening  of  the  limb  inti- 
mates to  us  that  the  bones  are  wasting,  which  is  otten  confirmed 
by  small  fragments  and  scales  of  bone  coming  away  along  with 
the  matter.  Finally,  When  the  matter  ceases  to  flow,  the  fistu- 
las to  close,  the  limb  to  shorten  still  more,  and  the  pains  to  sub- 
side, then  the  bones  come  into  actual  contact,  granulate,  unite, 
and  anchylose  firmly  in  due  time,  for  the  hectic  ceases,  the  ap- 
petite returns,  and  the  cure  goes  on  well,  if  only  the  patient  can 
survive  the  degree  of  debility  already  incurred. 

This  final  destruction  of  the  joint  is  the  ordinary  issue  of  the 
disease,  for  where  the  bones  are  once  thoroughly  diseased,  they 
are  in  general  carious,  or  in  other  terms,  dead,  or  (as  we  should 
say  of  soft  parts)  gangrenous  to  some  extent.  The  carious  part 
then  must  be  separated;  the  bones  which  enter  so  slowly  into  dis- 
ease, must  of  course  recover  slowly  ;  but  besides  the  extent  of 
surface,  the  disease  is  attended  in  its  first  stage  with  so  little 
pain,  the  patient  walks  so  long  while  the  disease  is  forming,  and 
the  joint  bears  so  entirely  the  whole  weight  of  the  body,  that 
being  once  diseased  it  cannot  easily  recover  ;  it  is  indeed  en- 
tirely ruined  in  its  structure  almost  before  the  disease  is  ob- 
served. 

The  cure  in  the  bruise  of  the  acetabulum  is  to  be  effected  by 
leeches,  fomentations,  blisters,  general  bleeding,  and  perfect 
quiet ;  but  in  this  scrophulous  disease  of  boys,  the  cure  is  best 
conducted  by  cold  bathing,  generous  food,  wine,  and  whatever 
will  contribute  to  the  restoration  of  the  health  and  strength.  The 
immediate  progress  of  the  disease  is  best  antagonized  by  the 
counter  irritation  of  blisters,  or  rather  of  deep  and  large  issues 
upon  the  hip,  or  by  the  application  of  cauteries  (the  oldest  and 
perhaps  the  best  method  of  cure)  along  with  prudent  openings, 
and  careful,  but  unofficious  surgery.  But  the  object  of  chief 
importance  in  promoting  the  anchylosis,  is  to  prevent  motion, 
for  even  the  weight  of  the  limb  is  very  painful,  the  very  turning 
in  bed  inflames  the  part  and  interrupts  the  process  ;  and  quacks, 
by  turning  and  twisting  joints  during  this  process  (the  patient 
being  in  a  fair  way  of  being  cured)  have  caused  death. 

When  the  period  of  ulceration,  granulation,  and  healing  ol 
the  bones  arrives,  a  remarkable,  but  very  gradual,  shortening 
of  the  limb  takes  place,  because  the  bones  must  first  be  ulcerat- 


168  Affection  of  the  Hip-Joint. 

cd,  then  fall  into  closer  contact,  then  granulate,  and  then  adhere, 
before  the  anchylosis  is  complete.  During  the  whole  of  this 
process  the  parts  are  wasting,  coming  closer  and  uniting  :  at  least 
it  most  generally  is  so.  I  observe  in  anchylosis,  even  of  the 
kner-joint,  where  the  bones  are  flat,  and  the  cartilages  remark- 
ably thin,  that  there  is  a  very  remarkable  shorteningof  the  limb. 
When  such  a  suppuration  and  caries,  beginning  in  the  bones 
themselves,  does  happen,  not  in  boys,  but  in  adults,  not  from 
any  constitutional  disease,  but  from  a  blow,  the  blow  is  in  a 
vers  particular  direction,  and  affects  only  the  bone;  for  it  is  not 
a  blow  upon  the  trochanter  striking  the  head  of  the  bone  down- 
wards, so  as  to  bruise  the  soft  parts  at  the  bottom  of  the  ace- 
tabulum ;  but  it  is  by  a  person  making  a  desperate  leap  and 
lighting  fair  upon  the  feet,  tor  the  head  of  the  thigh-bone  is  then 
struck  upwards  against  the  deepest  part  of  the  acetabulum, 
where  the  Os  Innominatum  is  particularly  large  and  firm ;  the 
bone  only  is  bruised,  there  is  no  immediate  pain,  the  lameness 
comes  on  slowly,  the  disease  usually  makes  that  slow  progress 
which  is  described  in  the  case  related  in  the  foot  note  from  the 
Posthumous  Works  of  Justamond.* 


*  A  woman  about  eight  and  twenty  years  of  age,  laden  with  a  bafket  full  of 
bottles,  having  jumped  doivn  a  feiv  flairs  in  going  into  a  cellar,  preferred  the 
centre  of  gravity  of  the  upper  parts  upon  the  left  thigh  and  leg  fo  well,  that  fbe 
kept  herftlf  from  falling ;  but  fhe  experienced,  in  the  infide  of  the  joint  of  the  hip,  a 
violent  Jhock,  which  was,  however,  attended  only  with  a  very  bearable  degree  of  pain, 
fince  fhe  was  able  to  continue  her  ordinary  work  for  more  than  a  fortnight,  "without 
complaining.  But  fhe  dill  felt,  in  walking,  a  pain  which  gradually  increafed,  from 
the  continual  exercife  fhe  was  obliged  to  ufe  in  her  capacity  of  fervant :  the  diffi- 
culty of  motion  increafed  with  the  pain ;  and  both  the  one  and  the  other,  three 
monthi  after  the  accident,  were  grown  fo  much  worfe,  that  the  woman  was  no  lon- 
ger able  to  fupport  herfelf  upon  that  iimb  At  this  period  fhe  came  into  the  hof- 
pital  where  1  attended ;  different  embrocations  were  ufed  to  the  upper  part  of  the 
thigh,  but  without  any  effed ;  refolutive,  anodyne,  and  maturacing  cataplafms, 
were  then  applied,  becaufe  a  tumour  manifefted  itfelf  at  the  upper  pofterior,  and 
external  part  of  the  thigh,  which  feemed  tending  to  fuppuration.  A  fever  came 
on;  and  when  the  abfeefs  became  evident,  all  the  openings  and  counter- openings 
were  made,  which  the  finufes  the  pus  had  formed,  required  ;  the  matter  which 
came  out,  had  no  kind  of  offenfive  fmell :  it  brought  away  along  with  it  fome 
fmall  bony  particles,  and  an  oleaginous  fluid  floated  on  the  furface ;  the  inci- 
fions  were  lengthened  as  much  as  it  was  thought  neceffary,  fetons  were  parted, 
and  during  the  courfe  of  the  treatment,  vulnerary  and  detcrfive  injections  were 
tried,  fuch  as  were  imagined  to  be  belt  fuited  to  the  ftate  of  the  parts.  At  differ- 
ent intervals  fmall  portions  of  bone  came  away,  feparated  either  from  the  head  of 
the  thigh-bone,  or  from  the  cavity  of  the  joint,  into  which  feveral  of  the  finufes 
penetrated.  A  flow  fever  and  a  marafmus,  which  is  its  ufual  attendant,  deftroyed 
the  patient  between  three  and  four  months  after  her  admiffion  into  the  hofpital. 
Upon  examining  the  feat  of  the  difeafe,  I  found  the  capfular  ligament  almoft  de- 
ftroyed, the  round  ligament  totally  confumed,  the  head  of  the  thigh-bone  carious  in  all 
its  furface,  and  even  to  a  confiderable  depth  in  its  centre;  the  cavity  of  the  joint  ivat 
alfo  attacked  ivith  caries  throughout  its  whole  extent ;  r.nd  I'flly,  its  cartilaginous  bar' 
der  -was  completely  deftroyed. 


The  Diagnosis  Recapitulated,   *  169 


CONCLUSION. 

A  slight  and  easy  pathology  of  these  various  accidents,  and 
an  accurate  diagnosis,  is  all  that  I  have  aimed  at  in  this  dis- 
course ;  nor  do  I  know  of  any  subject  in  surgery  which  so  well 
merits  a  careful  recapitulation.  The  disorders  which  njeed  to 
be  distinguished  from  each  other  are,  fracture,  luxation,  bruise 
of  the  acetabulum,  and  the  scrophulous  disease  of  boys,  seated 
unquestionably  in  the  bones  ;  and  the  chief  signs  are,  the  length 
of  the  limb,  the  direction  of  the  toe,  the  place  of  the  trochanter, 
the  elongation  or  shortening  of  the  limb,  and  the  manner  in 
which  it  turns,  when  moved  by  the  surgeon. 

First,  We  are  assured  that  the  thigh-bone  is  luxated  down- 
wards, when  the  accident  has  been  a  twist  of  the  limb,  or  a 
blow  upon  the  very  top  of  the  great  trochanter;  when  the  thigh  is 
elongated  three  inches  or  more  ;  the  toe  turned  outwards,  in  a 
splay-foot  posture,  and  kept  straddling  away  from  the  body  with 
great  pain.  This  luxation  is  accompanied  with  a  proportioned 
displacement  of  the  great  trochanter  ;  the  hip  is  flattened,  and 
in  lean  people  you  can  distinguish  the  head  of  the  bone  rolling 
in  the  groin,  though  not  in  fat  subjects,  nor  in  women  whose 
pelvis  is  broad  and  flat. 

Secondly,  We  distinguish  luxation  upwards  by  the  remark- 
able shortening  of  the  limb,  by  the  ham  being  crooked,  the  knee 
of  the  luxated  side  turned  close  in  under  the  thigh  of  the  sound 
side,  and  the  toe  turned  inwards,  or  almost  backwards.  The 
great  trochanter  rises  very  high,  and  the  thigh  is  flattened  in 
this  case,  as  much  as  the  hip  is  in  the  last  mentioned.  The  pa- 
tient lies  on  his  sound  side,  almost  on  his  face,  and  when  you 
take  hold  on  the  leg  which  stands  up,  and  begin  to  turn  it,  you, 
by  laying  your  hand  over  the  most  tumid  part  of  the  haunch, 
feel  first  (because  it  is  the  most  prominent  point)  the  rolling  of 
the  trochanter,  and  then  by  carefully  examining  and  turning  the 
thigh-bone,  you  at  last  distinguish  the  head  of  the  bone. 

Thirdly,  When  the  neck  of  the  thigh-bone  is  fractured,  the 
limb  is  remarkably  shortened,  the  trochanter  is  higher  than  its 
natural  place,  the  thigh  is  flattened,  the  pain  is  exquisite,  and 
the  general  appearance  is  that  of  a  thigh-bone  luxated  upwards ; 
but  the  moment  you  take  the  limb  in  your  hand,  you  distinguish 
this  from  all  other  accidents  ;  for  while  the  limb  is  so  remarka- 
bly shortened  as  to  leave  no  doubt  of  some  very  essential  injury 
having  happened,  it  yet  turns  so  easily  as  to  prove  that  it  is  not 
luxated,  and  indeed  it  turns  so  loosely  as  to  prove  that  the  limb 
has  not  that  degree  of  steadiness  which  the  natural  connexion  of 
the  shaft  of  the  thigh-bone,  with  its  head  and  neck,  should  give. 

Y 


170  The  Diagnosis  Recapitulated. 

The  limb  is  shortened,  but  is  easily  lengthened  ;  the  toe  is  turn- 
ed out,  but  is  easily  turned  in  again  ;  in  short,  the  manner  in 
which  it  moves  will  satisfy  you  at  once  that  the  shaft  is  separa- 
ted from  the  head  of  the  bone.  If  crepitation  be  not  among  the 
immediate  signs  ot  this  fracture,  it  is  because  the  bones  are  not, 
as  in  other  fractures,  opposed  to  each  other  ;  if  crepitation  be 
felt  afterwards,  it  is  only  when  the  limb  is  extended,  and  the 
bone  set,  or  in  other  terms,  the  broken  parts  regularly  opposed 
to  each  other. 

Fourthly,  When  the  patient  has  fallen  upon  the  trochanter, 
or  received  a  blow,  when  the  head  of  the  bone  has  been  struck 
down  into  the  socket  with  violent  pain,  when  the  patient  be- 
comes instantly  lame,  and  lies  in  a  crooked  posture,  with  the 
knee  of  the  injured  limb  bent  in  under  that  of  the  sound,  (in  or- 
der to  raise  up  the  head,  as  much  as  possible,  from  the  inflamed 
socket  where  its  pressure  occasions  pain)  when,  along  with 
these  appearances,  we  are  perfectly  sensible  that  the  limb, 
though  crooked,  is  not  shortened,  when  we  find,  that  though 
when  moving  it  occasions  dreadful  pain,  yet  it  does  move  easily 
and  steadily,  we  may  be  assured  that  the  fall  has  occasioned 
merely  a  bruise  in  the  acetabulum.  In  this  case  the  patient  lies 
crooked  in  bed,  the  pain  is  exquisite,  he  cannot  bear  to  nave 
the  joint  touched,  or  the  limb  moved,  the  slightest  motion  is 
terrible  to  him,  to  stretch  out  the  limb  is  excruciating.  The 
surgeon  has  not  leave  to  handle  the  limb  freely,  or  is  prevented 
by  his  own  timidity,  and  by  the  shrieks  of  the  patient;  he  mis- 
takes the  nature  of  the  injury,  makes  cruel  attempts  to  reduce 
a  bone  which  is  neither  fractured  nor  luxated,  and  does  essen- 
tial injury  to  a  joint  already  much  injured  ;  perhaps  he  never 
doubts  of  the  limb  being  luxated  or  fractured,  till,  after  some 
months  of  the  severest  misery,  the  pain  remits,  the  patient  be- 
gins to  walk,  and  recovers  at  last  the  use  of  his  limb. 

This  mi  re  bruise  of  the  acetabulum  is  unquestionably  the 
disease  which  Prtit  describes,  where  he  says  that  he  has  often 
prevented  it  coming  to  any  height  by  applying  astringent  so- 
lutions, and  defensives  made  of  alum,  and  whites  of  eggs, 
with  spirits  of  wine.  Rest  is  of  chief  service,  but  rest  need 
hardly  be  recommended  to  one  in  such  exquisite  torture,  whose 
pains  are  aggravated  by  the  slightest  motion. 

Fifthly,  When  a  scrophulous  boy,  under  eighteen  years  of 
age,  has  laboured  long  under  a  disease  of  this  joint,  where 
th  re  is  great  lameness,  little  pain,  a  puffy  swelling,  an  elonga- 
tion of  the  limb,  if  there  come  at  last  acute  pain,  hectic  fever, 
symptoms  of  internal  suppuration,  and  at  last  an  abscess  upon 
the  hip  nr  groin,  you  know  that  it  is  a  constitutional  disease, 
that  it  is  seated  in  the  bones,  that  it  is  analogous  to  the  white 


Of  Lithotomy.  171 

swelling  of  the  knee,  or  curvature  of  the  spine  ;  hut  unlike  the 
disease  of  the  knee-joint,  this  ot  the  hip  cannot  be  amputated, 
and  the  boy  must  go  through  the   fiery   ordeal,  and  often  dies 
from  fever  and  irritation,  great  profusion  ol   matter,  and  caries 
ol  the  bones.      If  he  survive,  it  is  usually  with  a  limb  emaciat- 
ed, crooked,  hanging  in  air,  and  fixed  by  the  anch\  losis  o*  the 
femur  with  the  haunch  bone.     The  chief  cause  of  such  disease 
is  the  scrophulous  condition  of  the  system,  the  imperfect  ossi- 
fication of  the  bones,  the  great  extent  ul  diseased  surface,  and 
from  the  occasional  shocks  which  this  great  joint  suffers,  in  con- 
sequence of  its  supporting  continually  the  whole  weight  of  the 
body.     The  chiet  danger  ol  the  disease  is  the   boy  lee  ling  but 
too  little  pain   to  make  himself   or  his  parents  sensible  ot  the 
danger  ;   if  it  be  not  chiefly  in  consequence  of  the  pressure  and 
motion  that   such  disease  goes  on  to  the  last  stage  ol  caries,  yet 
certain  it  is,  that  under  the  pressure  of  the  whole  weight  of  the 
body   such    a  disease  cannot   be  cured  ;   the  only  chance,  then, 
of  recovery,  is  trom  wine,  generous  diet,  cold  bathing,  caustics, 
issues,  and  absolute  rest. 


DISCOURSE  XII. 

OF  LITHOlOMT. 
Preliminary  Observations. 

\_)  F  all  the  operations  of  surgery,  lithotomy  is  that  in  which  the 
true  principles  of  the  operation  may  be  most  safeh  deduced 
from  the  anatomy  of  the  parts.  To  conjecture  a  priori,  which 
form  of  incision  would  be  attended  with  fewest  dangers,  would 
not  be  difficult  ;  but  now  that  we  have  before  us  suv.h  a  suit  of 
experiments,  performed  in  various  countries  by  the  greatest 
masters  in  surgery,  and  accompanied  with  such  authentic  re- 
cords of  their  various  successes,  we  are  able,  from  experience 
as  well  as  theory,  to  resolve  that  important  problem ;  "  How 
we  mav,  with  least  danger,  open  our  way  into  the  bladd<  r,  for 
the  extraction  of  the  stone."  i  And  the  universal  adoption  of 
the  lateral  operation  invented  by  Chesselden,  sufficiently  attests 
its  superiority  to  all  others. 

Accustomed  with  teaching,  I  have  had  occasion  to  observe 
that  the  mind  of  the  surgeon  is  ill  at  ease,  who  has  to  perform 
an  operation  for  which  he  has  no  theon,  ;  he  must  operate  with 
little  decision  who  merely  imitates  the  motions  of  others. 

I  have  also  observed  that,  to  perform  an  operation  like  this 


172  Of  Lithotomy. 

with  an  intrepid  spirit  and  steady  hand,  the  mind  of  the  young 
surgeon  must  be  composed ;  he  must  have  an  entire  and  perfect 
confidence  in  his  own  knowledge  ;  he  must  be  familiar  with  the 
structure  of  the  parts  ;  he  must  see  them  exposed  in  every  variety 
of  posture,  and  must  have  their  relations  to  each  other  explain- 
ed ;  he  must  dissect  them  often,  to  make  this  knowledge  fami- 
liar, and  to  acquire  dexterity  and  address,  tor  no  operation  in 
surgery  can  be  so  properly  defined  a  dissection  ptrlormed  on 
the  living  body  as  this.  While  the  young  surgeon  studies  the 
connections  and  relations  of  these  parts,  he  must  also  be  in- 
structed in  all  the  accidents  which  may  occur;  he  must  be 
taught  to  foresee  even  possible  difficulty,  that  he  may  not  in  the 
midst  of  an  operation  be  overcome  with  the  sudden  apprehen- 
sion of  some  interruption  which  he  does  not  understand.  The 
teacher  who  is  to  describe  so  eventful  an  operation  as  this  of 
lithotomy,  must  first  explain  in  detail,  circumstantially  and  se- 
parately, each  important  movement  of  the  hand  or  instruments, 
and  every  precaution  with  which  each  is  to  be  accomplished ; 
and  then  close  his  lesson  with  such  a  rapid  enumeration  and  de- 
scription of  the  successive  acts,  as  will  leave  a  vivid  impression 
on  the  mind  of  the  young  surgeon  of  the  manner  in  which  he  is 
to  proceed.  This  last  description  should  serve  him  as  a  dra- 
matic picture  of  what  he  is  to  perform,  which  he  may  look  up- 
on anew  every  time  he  has  to  operate. 

Before  I  proceed  to  describe  the  several  stages  of  the  opera- 
tion of  lithotomy,  there  are  some  preliminary  points  to  be  ex- 
plained? which  relate  notto  the  dress  of  the  patient,  northe  height 
of  the  table,  but  to  the  main  design  of  the  operation,  and  es- 
pecially to  the  posture  of  those  very  moveable  parts,  the  rec- 
tum and  bladder,  with  regard  to  each  other,  and  the  manner 
in  which  the  surgeon  should  feel  and  ascertain  every  thing  that 
is  interesting  to  him.  The  kind  and  degree  of  distress  which 
your  patient  suffers,  will  enable  you  to  guess  at  the  state  of  the 
parts  ;  in  a  boy  who  cannot  have  passed  many  years  in  this  con- 
dition, whose  parents,  from  observing  his  pulling  out  the  penis 
and  pressing  the  thighs,  and  crying  when  passing  the  urine,  can 
ascertain  both  the  duration  of  his  complaints,  and  the  degree  in 
which  his  health  is  affected,  you  are  sure  of  every  thing  favour- 
able fori  your  operation;  for  boys  are  naturally  healthy;  the 
stone  has  not  with  them  time  to  acquire  any  uncommon  size, 
it  usually  is  small  like  a  gall-nut,  and  very  rough  and  irregular 
on  its  surface  ;  the  bladder  is  not  contracted  nor  ulcerated  ;  you 
can  feel  the  stone  with  the  fingers,  in  the  rectum,  and  press 
it  forward  so  as  to  make  it  prominent  in  the  perinaeum ;  in  a 
healthy  boy,  with  a  small  stone  recently  formed,  you  undertake 
the  operation  with  confidence.     In  an  adult,  who  retains  much 


Of  Lithotomy.  173 

urine,  who,  though  the  symptoms  of  stone  are  decisive,  yet 
passes  long  intervals  with  little  pain,  in  whose  urine  there  is  not 
great  sediment  of  mucus,  and  seldom  any  blood,  with  whom 
the  paroxysms  ot  the  disease,  i.  e.  the  temporary  inflamed  and 
irritated  state  of  the  bladder,  is  not  frequent ;  the  bladder  is  pro- 
bably capacious,  the  stone  small,  and  the  state  ot  the  parts  most 
favourable  lor  opt  rating.  But  the  scene  is  sadly  reversed  when 
the  patient,  shrinking  irom  the  pains  of  the  operation,  has  long 
endured  the  tortures  of  the  stone  :  whtn  he  has  endured  this 
disorder  for  many  years,  he  is  pale,  languid,  and  emaciated  ; 
the  parts  are  unfavourable  to  the  operation,  and  his  constitu- 
tion to  recovery  :  he  can  retain  but  one  or  two  ounces  ot  urine: 
the  bladder  is,  by  its  frequent  contractions,  thickened  in  its  coats, 
and,  its  inner  and  most  delicate  surlace  being  in  almost  continual 
contact  with  the  stone,  he  teels  excruciating  pains  in  the  glans 
penis  every  time  he  passes  his  urine  :  when  he  walks,  he  has  a 
gravitating  and  dragging  feeling,  accompanied  with  tenesmus  or 
diarrhoea,  from  the  increasing  size  of  the  stone,  by  which  his 
paroxysms  of  particular  distress  are  frequently  renewed  ;  his 
urine  is  so  mixed  with  mucus,  that,  of  the  quantity  which  he 
passes  into  a  glass  for  our  inspection,  the  urine  being  poured 
off,  one  half  remains  a  pure  white  mucus,  and  each  paroxysm 
of  pain,  especially  if  it  arise  from  walking,  is  accompanied  w  ith 
a  discharge  of  blood  :  the  day  he  passes  in  almost  unremitting 
torture,  and,  during  the  night,  he  is  every  hall  hour  on  his 
knees,  straining  to  pass  his  urine  with  dreadful  pain.  In  such 
a  patient  the  bladder  is  small,  contracted,  subject  to  inflamma- 
tion ;  from  frequent  paroxysms  of  the  stone,  the  parts  art  in  a 
state  sometimes  peculiarly  disposed  to  inflammation,  and  never 
favourable  to  the  operation,  while  the  strength  and  constitution 
are  exhausted  by  suffering  and  want  of  rest. 

It  is  only  when  your  patient  is  free  from  pain,  when  he  has 
had  a  long  interval  alter  a  paroxysm  of  pain,  when  he  is  free 
from  irritation  and  fever,  and  in  no  danger  from  the  infection 
of  any  reigning  epidemic,  that  )ou  can  venture  to  perform  the 
operation.  You  wait  lor  the  more  favourable  seasons  of  spring 
or  autumn  :  you  nourish  and  strengthen  your  patient,  it  ex- 
hausted, and  prepare  him  so  by  opiates  and  the  warm  bath,  as 
to  ensure  a  favourable  state  of  the  skin  and  bowels.  The  sea- 
son of  any  epidemic  disease  is  much  to  be  avoided.  I  have 
frequently,  during  the  prevalence  of  influenza,  or  of  dysenteric 
diseases,  been  cruelly  disappointed  in  the  adhesion  of  wounds, 
after  common  operations,  in  cases  of  the  most  simple  incisions, 
as  in  the  extirpation  of  a  cancerous  breast  ;  but  the  inflamma- 
tion, which  merely  prevents  adhesion  and  retards  the  cure  in 
common  operations,  produces  in  this,  where  the  wound  is  so 
near  the  viscera,  abdominal  inflammation  and  death. 


174  Of  Lithotomy. 

And  let  me  advise  the  surgeon  to  be  slow  in  pronouncing 
his  opinion,  to  be  careful  to  ascertain  the  existence  ot  the  stone, 
by  sounding,  and  to  feel  it  also  by  introducing  the  fingers  into 
the  rectum,  and  to  establish  and  authenticate  his  own  opinion 
by  a  regular  consultation,  before  he  presumes  to  operate.  He 
should  almost  live  with  his  patient  tor  some  days,  ior,  unless  he 
inquire  carefully  into  his  history,  he  cannot  proceed  with  confi- 
dence, or  his  confidence  may  draw  him  into  dreadful  errors. 
The  patient  may  have  no  stone,  but  an  ulcerated  and  thickened 
bladder  ;  he  may  have  a  stone,  but  too  small  to  require  so  dread- 
ful an  operation,  one  which  the  patient  might  be  able  to  engage 
in  the  urethra,  and  pass  naturally  by  drinking  floods  of  diluents, 
and  passing  the  urine  upon  his  knees;  a  small  stone,  being  im- 
pelled by  the  force  of  the  urine  into  the  urethra,  sometimes 
forms  there  a  sac  for  itself,  and  the  sound  grating  along  this 
small  calculus,  in  passing  along  the  urethra,  persuades  the  sur- 
geon of  the  existence  of  a  stone  in  the  bladder :  a  patient  has 
been  unfortunately  cut  for  a  stone  so  small,  that  it  has  been 
swept  out  along  the  channel  of  the  gorget  with  the  flood  of 
urine,  and  none  been  found  to  seize  with  the  forceps  ;  at  other 
times  a  small  calculus,  of  a  cherry-stone  size,  has  been  found 
in  the  hinge  of  the  forceps,  and  such  accidents  have  been  men- 
tioned with  as  much  indifference  as  if  the  surgeon  were  not  re- 
sponsible for  the  cruelty  and  folly  of  thrusting  a  gorget  into  the 
bladder  of  a  patient  whose  stone  was  so  small  as  to  be  passed 
by  the  urethra.  In  short,  these  are  accidents  which  nothing 
but  uncommon  precaution,  and  a  most  faithful  attention  to  the 
complaints,  feelings,  and  whole  history  of  the  patient,  can  de- 
tect or  prevent. 

However  distinctly  the  sound  may  plump  upon  the  stone,  and 
satisfy  every  one  of  its  existence,  the  surgeon  never  is  to  omit 
introducing  one  or  two  fingers  into  the  rectum ;  from  this  mode 
of  inquiry,  various  circumstances  may  be  discovered,  and  in- 
estimable advantages  arise  to  the  surgeon,  who,  in  place  of  imi- 
tating the  motions  of  other  operators,  proceeds  with  intelligence 
and  design.  I  hold  this  mode  of  examination  to  be  little  less 
important  to  the  operator  who  cuts  with  the  knife  or  gorget, 
than  to  him  who  cuts  on  the  gripe  :  By  introducing  two  fingi  rs 
into  the  rectum  he  feels  the  staff  distinctly,  upon  which  he  is  to 
perform  the  most  delicate  part  of  his  incision  :  he  feels  the  po- 
sition of  the  rectum,  which  he  is  to  keep  out  of  the  way  of  his 
instruments  :  he  distinguishes,  through  the  walls  of  the  rectum, 
the  membranous  part  ot  the  urethra,  which  is  to  be  his  aim  if 
he  cut  with  the  gorget,  and  the  prostrate  gland,  which  he  is 
to  divide,  if  he  cuts  with  the  knife  :  he  feels  the  manner  in 
which  the  stone  lies  in  the  bladder,  which,  after  his  incisions, 


Of  Lithotomy,  175 

he  is  to  grasp  with  the  forceps :  if  the  stone  be  small,  he  may  not 
feel  it  ven  distinctly  ;  but  it  it  be  large,  it  falls  low  towards  the 
ne ck  of  the  bladder,  is  easily  felt,  its  very  form  may  almost  be 
distinguished,  the  staff  being  plainly  felt  passing  under  the 
stone,  when  large,  and  holding  it  in  its  bend  or  curvature.  The 
surgeon,  bv  occasional  examinations,  may  almost  estimate  its 
size,  and,  if  he  do  not  expressly  proportion  his  incision  to  its 
size,  may  at  least  avoid  the  error  of  making  a  great  incision  for 
a  small  stone,  or  the  still  greater  danger  of  making  a  small  in- 
cision when  the  stone  is  very  large  ;  and  when  the  stone  is  so 
large  as  to  require  to  be  broken  by  strong  forceps,  he  may  al- 
ways be  aware  of  the  nature  of  the  operation  he  is  to  perform. 
I  remember  to  have  been  called  to  a  consultation,  in  which  the 
gentleman,  who  invited  the  consulting  surgeons,  wrote  in  these 
terms  :  **  To  consult  upon  the  case  of  a  patient  who  has  a  stone 
in  the  urethra,  and  another  in  the  bladder."  The  patient,  in 
fact,  had  laboured  long  under  the  disease,  the  stone  had  increas- 
ed to  an  enormous  size  ;  upon  passing  the  sound,  it  encountered 
the  stone  almost  before  it  had  entered  the  bladder,  so  low  was 
the  stone  depressed  by  its  own  weight,  and  the  patient's  strain- 
ing dilating  in  some  degree  the  neck  of  the  bladder  and  pro- 
jecting into  it.  Upon  examining  by  the  rectum,  I  felt  a  stone 
nearlv  the  size  of  the  fist,  and  intreated  the  surgeon  to  have 
strong  forceps  in  readiness  to  break  it  in  case  of  difficulty. 
When  we  were  met  for  the  operation,  I  used  the  freedom  of 
asking,  "  Whether  forceps  were  at  hand  to  break  the  stone  ?" 
He  said,  M  No  ;  that  he  had  sent  for  forceps,  such  as  I  wished, 
but  could  not  easily  procure  them."  Then  1  said, 4f  Sir,  if  you 
value  vour  own  reputation,  or  your  patient's  life,  refrain  from 
operating  till  you  are  better  provided,  which  you  may  easily  be 
to-morrow  morning;  to  perform  this  operation  in  the  ordinary 
way,  will  be  murder."  He  turned  about  and  proceeded  with 
his  operation  :  the  scene  which  ensued  was  dreadful  ;  two  or 
three  forceps  were  successively  twisted,  or  broken;  all  present 
were  in  the  most  distressing  perplexity.  Mr.  Wood  bethought 
himself  of  a  p  iir  of  large  and  strong  forceps,  which  had  lain  as 
lumber  among  his  apparatus  ;  these  were  sent  lor  to  his  house, 
and  with  them  the  stone  was  extracted  ;  but  the  operator  had 
never  one  moment  refrained  from  labouring  with  one  instru- 
ment or  another;  the  patient  had  struggled  under  his  hands  a 
full  hour,  in  the  most  dreadful  agonies  ;  I  need  hardly  say,  that 
in  two  days  he  died. 

Not  to  break  the  stone,  when  of  so  uncommon  a  size,  is  cruel 
and  dangerous,  and  no  one  accustomed  with  this  operation  will 
scruple  to  do  so  for  fear  of  fragments  of  the  stone  remaining  in 
the  bladder,  for  he  must  be  conscious  that  he  seldom  operates 


176  Of  Lithotomy.    . 

without  the  forceps  chipping  off  small  fragments  of  the  stone, 
which  are  more  dangerous  than  the  fragments  ot  a  stone  de- 
signedly broken,  as  they  are  less  observed. 

The  condition  of  the  rectum  and  bladder  should  be  an  object 
of  particular  attention.    The  bowels  must  be  emptied  by  a  purge 
two  days  before  operating,  for  fulness  and  irritation  of  the  bow- 
els, will  dispose  to  abdominal  inflammation.    The  rectum  must 
be  emptied  by  a  clvster  on  the  morning  of  the  operation,  lest 
the  fulness  of  the   gut  should  expose  it  to  be  wounded  :  This, 
if  not  a  fatal,  is  yet  a  blundering  wound,  of  which  the  surgeon 
should  be  much  ashamed :  although  we  have  the  best  authori- 
ty for  affirming  that  the  intestine  may  be  wounded  by  the  most 
dextrous   operator.     Chesselden   acknowledged    to    Mr.   Mo- 
rand,  that  he  had  twice,  in  operating,  wounded  the  rectum.    As 
it  is  chiefly  important  to  prevent  the  cutting  edge  of  the  gorget 
injuring  the  back  part  of  the  bladder,  it  is  of  the  first  import- 
ance, in  operating  with  the  gorget,  to  have   the  bladder  full ; 
the   fulness  of  the  bladder  allows  the  staff  to  be  turned  easily  to 
every  side  of  the  bladder,  in  feeling  for  the  stone  ;  it  allows  the 
surgeon  to  set  the  staff  before  cutting,  in  the   precise  direction 
he  wishes  to  have  it.      The  fulness  of  the  bladder  presents  the 
fore  part  of  its  body,  viz-  that  where  the  prostate  surrounds  it, 
fairly  to  the  cutting  edge  of  the  gorget,  and  gives  the  bladder  a 
steadiness  to  resist  the  push.       This  fulness  of  the  bladder  pre- 
vents the  cutting  gorget  being  driven  through  the  fundus  among 
the  bowels,  and  the  quantity  of  urine  running  off  treely  along 
the  channel  or  hollow  of  the  gorget  indicates  to  the  operator, 
that  this,  the  most  dangerous  movement  in  the  operation,  is  pro- 
perly  performed.     The    patient   for  this   end  must  retain  his 
urine  four  or  five  hours  in  the  morning  of  operation  ;  in  boys, 
and  even  in  men,  a  linen  rag  must  be  tied  round  the  penis  to 
prevent  the  urine  flowing  off.     The  string  must  not  be  undone 
upon  introducing  the  staff  for  operation,  for  the  body  of  the  pe- 
nis is  so  compressible,  that  the  staff  passes  as  easily  when  the 
string  is  left,  as  when  it  is  taken  away.     I  have  often  been  pro- 
voked to  see  the  string  taken  off,  the  staff  introduced,  and  the 
whole  of  the  urine  allowed  to  run  off  by  the  groove  of  the  staff, 
in  the  very  moment  in  which  the  surgeon  is  about  to  drive  his 
gorget  into  the  bladder. 

As  one  great  purpose  of  many  things  which  the  surgeon  does 
immediately  previous  to  the  operation,  is  to  ascertain  the  re- 
lative posture  of  the  parts,  and  revive  his  own  recollections  of 
the  several  points,  he  should  never  fail  to  introduce  the  staff 
himself,  though  often  this  is  committed  to  the  assistant.  May 
not  an  unskilful  assistant  drive  the  point  of  the  staff  through 
the  membranous  part  of  the  urethra,  and  lodge  it  between  the 


Of  Lithotomy.  177 

rectum  and  bladder  where,  of  course,  the  gorget  when  driven 
along  will  follow  the  groove  ?  Is  it  not  a  satisfaction  to  the  sur- 
geon to  pass  the  staff  himself,  that  he  may  do  it  gently  without 
irritating  the  parts  ;  that  he  may  feel  and  distinguish  any  rub 
from  any  small  calculus,  sticking  in  the  urethra  ;  that  he  may- 
lodge  fairly  in  the  bladder  that  grooved  directory,  which  is  to 
guide  the  most  important  stroke  of  his  knife  ;  that  he  may 
plump  his  staff"  against  the  stone,  and  feel  it  distinct!)  before  he 
operates;  that  he  may,  after  introducing  the  staff,  pass  his  finger 
into  the  rectum,  feel  how  the  staff  lies,  incline  the  handle  ol  it 
to  the  right  groin,  and  so  protrude  the  heel  in  the  perinaeum 
where  he  is  to  cut  ?  Will  not  the  introducing  and  setting  the 
staff  and  feeling  its  curvature,  both  in  the  peringeum  and  from 
within,  give  the  operator  more  decision,  and  a  more  distinct 
recollection  of  what  he  has  next  to  perform  ?  To  deliver  the 
staff  to  the  assistant,  that  he  may  introduce  it,  is  a  slovenly,  a 
timid,  or  an  evasive  practice  ;  I  have  seen  this  often  done,  but 
it  always  seemed  to  me  that  the  man  who  dared  to  undertake 
the  operation  of  lithotomy,  was  doubtful  whether  he  could  in- 
troduce a  staff;  or  that  he  was  so  jealous  of  his  reputation  as  a 
rapid  operator,  that  he  would  not  allow  the  more  ignorant  of 
the  attendants  to  calculate  the  operation  as  begun,  when  he  was 
only  introducing  the  staff;  or  perhaps  he  feared  lest  his  hand 
should  be  unsteadied  by  some  slight  opposition  to  the  introduc- 
tion of  the  staff;  a  part  of  the  operation  which  should,  in  fact, 
by  reminding  him  of  all  the  important  relations  of  the  parts  in- 
spire him  with  steadiness  and  manly  resolution. 

There  is  a  gradation  in  the  length  and  curvature  of  the  in- 
struments which  are  on  various  occasions  to  be  introduced  in- 
to the  bladder.  The  catheter,  as  it  needs  not  enter  far  into 
the  neck  of  the  bladder,  though  it  should  always  be  as  big  as 
the  urethra  will  easily  admit,  should  not  be  long,  and  should 
have  a  very  gentle  and  simple  curve  :  the  sound,  with  which 
we  feel  for  the  stone,  must  be  round,  smooth,  longer,  and  more 
curved  ;  but  it  must  not  be  very  long,  nor  much  curved,  lest  it 
do  not  turn  easily  from  side  to  side  in  the  bladder ;  and  it  should 
be  introduced  when  the  bladder  is  moderately  full,  that  it  may 
be  turned  easily  in  various  directions  in  search  of  the  stone, 
which,  if  it  be  not  found  when  the  bladder  is  full,  or  the  patient 
seated,  or  lying  on  the  ground,  may  perhaps  be  felt  after  he  has 
been  permitted  to  empty  the  bladder,  or  allowed  to  stand  up. 
The  staff  along  which  the  surgeon  designs  to  run  the  gorget, 
should  have  a  prominent  heel,  that  it  may  be  easily  felt  through 
the  membranous  part  of  the  urethra  ;  it  should  have  a  wide 
^roove,  but  should  not  be  protracted-  into  a  beak,  lest  it  should 

Z 


1T8  Of  Lithotomy. 

hold  the  knob  of  the  gorget  too  long  engaged  in  the  groove,  and 
carry  it  so  deep  as  to  endanger  the  fundus  ot  the  bladdtr. 

The  posture  in  which  the  patient  is  bound,  is  horrible,  most 
oppressive,  but  vet  it  is  essential  to  the  performing  ot  an  opera- 
tion, where  the  slipping  of  one  instrument,  or  the  misgiving 
of  one  stroke  of  the  knife,  makes  the  difference, — of  safet)  or 
death.  He  must  be  made  to  grasp  his  feet  with  his  hands,  and 
secured  in  that  posture  by  strong  garters,  encircling  the  wrists 
and  ankles,  and  thus,  bended  into  a  curve,  he  rests  almost  up- 
on one  point  of  the  spine,  and  is  brought  so  near  to  the  edge  of 
the  table,  that  he  is  almost  suspended  in  air,  by  the  two  lateral 
assistants,  who  support  each  a  toot  and  an  arm.  Unless  the  pa- 
tient is  brought  thus  far  over  the  edge  of  the  table,  supported 
by  the  assistants,  and  his  breech  bolstered  up  by  a  pillow  ;  un- 
less his  breech  project  over  the  edge  of  the  table  ;  unless  the 
perinaeum  be  turned  almost  directly  upwards,  and  the  surgeon 
seated  low,  and  rather  under  his  patient,  he  cannot  pursue  his 
incision  so  far  beyond  the  tuber  ischii  as  he  should  do,  in  order 
to  cut  the  transverse  muscle,  for  the  incision  should  pass  the 
curvature  of  the  hip. 

The  patient  should  be  brought  out  for  operation,  dressed  in 
a  loose  gown,  stockings,  and  slippers  :  his  neck-cloth  should 
be  loosened,  or  a  light  silk  handkerchief  put  about  in  place  of 
it:  Three  medical  assistants  should  support  him,  one  on  each 
side  should  hold,  each,  a  leg  and  wrist,  supporting  the  sole  of 
the  foot  in  the  hollow  of  one  hand  ;  the  third  assistant  should 
support  his  head  and  shoulders,  and  keep  him  forward  accord- 
ing to  the  operator's  directions.  The  table  should  be  big,  firm, 
and  steady,  covered  with  a  folded  blanket,  with  one  or  two  small 
pillows  placed  for  the  head  to  rest  upon,  and  one  longer  and 
bigger  to  support  the  breech,  or  rather  the  loins ;  a  little  sand 
should  be  strewed  under  the  lower  end  of  the  table.  A  friend 
should  stand  by  to  speak  to  him,  to  encourage  and  support  him, 
and  to  give  him  occasionally  a  little  wine  and  water;  and,  as  no 
unseemly  contusion  should  be  allowed,  every  thing  on  the  ta- 
ble of  instruments  should  be  fairly  arranged,  and  every  atten- 
dant steady,  silent,  and  observing.  One  only  should  hand  the 
instruments;  while  the  assistant- surgeon,  taking  his  place  be- 
hind the  voung  man  who  supports  the  right  foot,  waits  there 
till  the  surgeon,  having  introduced  the  staff,  and  felt  and  placed 
it,  lays  it  down  towards  the  right  groin,  and  gives  it  to  him  in 
charge  ;  when  he  is  to  grasp  it  firmlv  and  hold  it  steady  with 
his  right  hand,  but  without  pressing  hard,  supporting  the  ttsti- 
cles  and  scrotum  with  tht  flat  palm  of  his  left  hand,  and  pulling 
slighth  upon  them  so  as  to  stretch  the  perinaeum,  and  make  it 
tense  for  the  incision.  ■ 


Of  the  External  Incision.  1 79 

Upon  the  table  are  placed,  -a  decanter  of  wine,  another  of 
cold  water,  and  a  large  glass  of  cool  wine  and  water,  which  may 
be  poured  into  a  small  tea-pot,  as  more  convenient  for  the  pa- 
tient in  the  awkward  posture  in  which  he  lies  ;  a  hasin  of  warm 
water,  with  the  forceps  and  scoops  in  it ;  and  in  this  basin  of 
water  the  surgeon  heats  the  staft  with  which  he  chooses  to  ope- 
rate. The  staff  he  chooses,  and  the  gorget  suited  to  the  size 
of  the  patient,  and  well  and  smoothlx  fitted  to  the  groove  of  the 
staff,  and  the  knife  with  which  he  is  to  tut,  are  laid  on  a  plate 
"pon  a  fine  cloth  or  towel.  These  instruments  lie  on  the  plate  ; 
rtie  staffs  and  forceps  and  scoops  are  placed  in  the  basin  of  hot 
water;  the  sponge,  for  wiping  the  wound,  in  another  basin  of 
warm  water:  the  netdlts,  tht  lint,  the  dry  spongt  s,  or  agaric, 
to  be  used  in  cases  of  unusual  hsetnorrhagy,  toguhtr  with  the 
canula,  round  which  the  sponge  or  lint  is  to  be  wrapped  in  case 
it  should  be  necessary  to  thrust  a  canula  into  tht  wound,  lie  be- 
hind the  basins  and  apart  ;  and  along  with  ihest  is  to  be  laid,  in 
another  basin  of  warm  water,  a  strong  s\  ringe,  or  a  large  glvster 
bag  and  pipe,  for  washing  out  am  small  calculi  or  fragments  of  a 
broken  stone.  When  the  surgton,  advancing  to  the  table,  thus 
arranged,  warms  the  gorget,  and  then  stuks  it  in  his  girdle  or 
apron  string;  warms  the  staff  and  oils  it,  with  the  purpose  of 
introducing  it;  twists  a  towel  into  his  girdle,  for  it  is  impossible 
to  perform  the  several  parts  of  an  opt  ration  neatly,  with  soiled 
hands ;  and  leaves  upon  the  plate  only  the  incision-knife,  which 
his  assistant  hands  him,  upon  receiving  the  sign  ;  and  some- 
times also  the  gorget  is  lelt  to  be  handed  by  the  assistant. 

The  operation  of  lithotomy,  as  performed  with  the  gorget, 
may  be  divided  into  these  stages :  1st,  The  external  incision, 
by  which  we  divide  the  skin  and  the  transverse  muscle  of  the 
perinarum  :  2dly,  The  internal  dissection,  by  which  we  divide 
the  fat  and  cellular  substance,  and  the  fibres  of  the  levator  ani 
muscle,  and  open  the  urethra:  3dlv,  The  settling  of  the  gorget 
in  the  groove  of  the  staff,  and  pushing  it  onwards  through  the 
prostate  gland  :  4thly,  The  introducing  the  forceps,  withdraw- 
ing the  gorget,  and  grasping  and  extracting  the  stone. 


SECTION    II. 

Of  the  External  Incision. 

The  general  belief  and  the  common  description  stands  thus  : 
"  That  you  are  to  make  \our  staff  protrude  in  the  perinseum, 
and  to  perform  your  external  incision,  bv  cutting  upon  the 
staff." 


180  Of  the  External  Incision. 

Nothing  is  more  untrue* ;  we  cut  far  from  the  staff :  and 
this  unfortunate  description  occasions  infinite  perplexity  to  the 
young  surgeon,  who,  in  setting  his  staff,  cannot  cause  it  to  be 
felt  in  that  place  where  he  must  perform  his  incision,  and  who, 
having  made  his  incision,  and  penetrated  to  a  considerable  depth 
without  feeling  the  staff,  continues  in  confusion  and  dismay. 

The  external  incision  relates  not  at  all  to  the  neck  of  the 
bladder,  nor  is  it  made  upon  the  curve  of  the  staff;  it  relates  to 
the  great  hollow  betwixt  the  rectum  and  tuber  ischii;  it  is  de- 
signed merely  to  open  the  way  into  this  hollow,  through  which 
the  stone  is  to  be  extracted ;  and  the  surgeon's  chief  care  must 
be,  after  cutting  through  the  skin  and  fat,  to  divide  the  transver- 
salis  perinsei  muscle,  and  all  the  ligamentous  fibres,  which  would, 
if  left  undivided,  oppose  the  extraction  of  the  stone.  The  in- 
cision begins  at  that  point,  an  inch  below  the  scrotum,  where 
the  heel  of  the  staff  is  felt,  and,  departing  from  that  point  and 
leaving  the  direction  of  the  staff,  it  passes  over  the  great  hollow 
in  a  line  betwixt  the  anus  and  tuber  ischii ;  the  incision  is  per- 
formed in  the  following  manner: — The  surgeon  seats  himself  on 
a  low  stool;  the  assistant  draws  the  testicles  upwards,  to  make 
the  perinseum  tense,  and  gives  a  slight  pressure  to  the  staff;  the 
operator  then  lays  his  left  hand  flat  over  the  right  buttock  oi  the 
patient,  so  that  the  palm  of  the  hand  lies  upon  the  tuber  ischii ; 
spreads  out  his  fingers  upon  the  perinseum,  as  in  the  posture  of 
displaying  a  ring  ;  by  pressing  first  two  or  three  times  with  the 
point  of  the  fore-finger  at  the  root  of  the  scrotum,  he  feels  the 
heel  of  the  staff;  and  then,  by  drawing  the  skin  of  the  perinseum 
towards  the  left  side  with  the  points  of  the  fingers,  he  makes 
the  lurk  betwixt  the  perinseum  and  the  hip,  even.  Then,  taking 
the  knife  (which  sometimes,  while  stretching  the  perinseum,  the 
surgeon  holds  in  his  mouth)  in  his  right  hand,  he  holds  it  light- 
ly like  a  writing-pen,  with  the  points  of  the  thumb  and  three 
fingers ;  begins  the  incision  about  an  inch  (in  a  big  man)  behind 
the  scrotum,  and  carries  it  downwards,  declining  regularly  to- 
wards the  hip,  till  it  terminates  apparently  upon  the  hip,  for 
though  the  incision  is  carried  regularly  in  the  middle  betwixt  the 
anus  and  tuber  ischii,  yet,  the  skin  being  tenser  to  the  side  ol  the 
tuber  ischii,  the  wound  seems  to  decline  towards  that  side. 
The  extent  of  the  wound  being  ascertained  and  marked  out  by 
this  first  stroke  of  the  knife,  three  inches  and  a  half  in  length, 
more  or  less,  according  to  the  bulk  of  the  patient,  or  the  size  of 
the  stone  ;  this  incision  beginning  behind  the  scrotum,  proceed- 
ing obliquely  towards  the  hip,  running  in  the  middle  betwixt 

*  Moft  furgeons  whom  I  have  feen  operate,  make  the  incifion  in  this  manner, 
cutting  confequently  through  the  corpus  fpongiofum  penis,  nor  have  1  feen  any- 
ill  confequences  from  it.    S. 


Of  Cutting  the  Urethra.  181 

the  anus  and  tuber  ischii,  or  holding  off  but  a  little  from  the  anus 
for  fear  of  wounding  the  rectum,  will  be  found  to  have  its  cen- 
tre nearly  opposite  to  the  anus  ;  and  it  the  whole  length  of  the 
incision  be  three  inches  and  a  half,  two  inches  ot  its  length  will 
lie  before  the  anus,  and  one  inch  and  a  half  behind.  The  fin- 
gers of  the  left  hand,  which  at  first  kept  the  skin  tense,  are  now- 
withdrawn  for  a  better  use.  The  fore- finger  now  guides  the 
knife,  and  the  operator  proceeds  to  dissect  through  tat  and  cel- 
lular substance,  and  muscular  and  ligamentous  fibres,  till  the 
wound  is  free  and  open,  till  all  sense  ot  stricture  is  gone  ;  for  it 
is  only  by  feeling  opposition  and  stricture  that  we  recognize  the 
transverse  muscle.  When  this  hollow  is  lairly  laid  open,  the 
external  incision,  which  relates  merely  to  the  free  extraction  of 
the  stone,  is  completed ;  and  the  operator  begins  to  leel  tor  the 
staff. 

SECTION    III. 

Of  Cutting  the  Urethra. 

The  incision  thus  made  is  into  the  hollow  of  the  pelvis  below 
the  place  of  the  staff,  which  is  to  be  telt  only  in  the  upper  angle 
of  the  wound.  If  it  were  his  design  to  operate  only  with  the 
knife,  the  surgeon  would  now  push  his  fingers  deep  into  the 
wound,  and,  by  the  help  of  the  fore-fingt  r,  dissect  lrom  the  ure- 
thra along  the  body  ot  the  gland,  till  he  distinguished  its  thick- 
ness and  solidity,  and  reached  the  back  part  ot  the  gland  ;  then 
plunging  his  knife  through  the  back  of  the  gland,  and  settling  it 
in  the  groove  of  the  staff,  he  would  draw  it  firml)  and  steadily 
towards  him,  pressing  the  knile  steadil)  into  the  groove  ot  the 
staff,  and  then,  the  tree  discharge  ot  the  urine  assuring  him  that 
the  gland  and  cervix  vesicae  were  divided,  he  would  lay  aside 
his  knife,  pass  the  left  fore-finger  into  the  bladder,  withdraw 
the  staff,  and  introduce  the  forceps. 

But  in  operating  with  the  gorget,  the  next  business  after  the 
outward  incision,  is  to  seek  out,  not  the  body  ot  the  prostate 
gland,  but  the  membranous  part  ot  the  urethra  ;  to  find  it,  the 
operator  turns  his  fore -finger  towards  the  uj  per  angle  ot  the 
wound  ;  feels  for  the  start  close  under  the  pubis,  where  it  lies 
close  upon  the  bone,  hardly  to  be  distinguished  lrom  it;  and  as 
the  operator  recognizes  the  transversalis  musele  only  b)  the 
feeling  of  resistance,  he  recognizes  the  membi  unous  part  of  the 
Urethra  only  by  the  nakedness  ot  the  sti .ff.  But  it  is  salest  to 
be  very  clear,  to  dissect  fairly  to  the  staff,  to  leel  not  merely 
the  membranous  part  of  the  urethra,  but  the  body  of  the  gland. 
In  this  stage  of  the  dissection  you  can  do  no  harm  ;  a  fair  dis- 


1S2  Of  introducing  the  Gorget. 

section  may  save  you  the  disgrace  and  danger  of  making  three 
or  four  unsuccessful  cuts  at  iheurtthra;  you  therelore  keep 
pressing  down  the  rectum,  with  the  mid-finger  a  little  crooked  ; 
with  the  lore- finger  pointed  nearly  upwards,  you  guide  the 
knife  in  dissecting  along  the  naked  part  of  the  staff,  and  the  body 
ol  the  gland  ;  and  when  all  is  fair,  and  you  are  prepared  to  strike 
into  the  urethra,  you  place  your  fore-finger  upon  the  apex  or 
point  ot  the  prostate  gland  ;  and  turning  the  edge  of  your  scal- 
pel upwards,  you  strike  it  firmly  thro^ign  the  urethra  into  the 
groove  ol  tne  staff,  and  draw  it  towards  you,  steadily,  along 
the  groove,  till  you  have  made  an  opening  such  as  you  cannot 
miss,  about  half  an  inch  in  length,  into  which  you  fix  the  nail 
of  your  left  fore-finger,  or  of  your  thumb,  and  prepare  to  in- 
troduce the  gorget.* 

SECTION    IV. 

Of  introducing  the  Gorget. 

Keeping  his  thumb-nail  firmly  fixed  in  the  groove,  the  sur- 
geon givrs  away  the  knife,  and  lifts  the  gorget ;  poises  it,  and 
then  holds  it  firmly  in  his  hand.  He  then  passes  the  gorget  in- 
to the  wound,  where  it  enters  pretty  deep  before  it  reaches  the 
staff;  then,  pointing  the  beak  of  the  gorget  to  the  groove  of  the 
staff,  he  lodges  it  fairly  in  the  groove,  and  running  it  once  or 
twice  backwards  and  forwards  to  be  sure  that  all  is  fair,  and 
holding  the  gorget  steady  with  the  right  hand,  and  reaching  the 
lelt  hand  over  the  pubis  to  receive  the  staff  from  his  assistant, 
he  lays  hold  of  the  handle  of  the  staff^  holds  it  steady  for  a 
moment,  then,  moving  the  gorget  with  the  right  hand,  feels  by 
the  left  whether  the  beak  runs  fairly  and  smoothly  in  the  groove  ; 
then,  the  two  hands  acting  in  concert  with  each  other,  the  ope- 
rator balances  the  staff  and  gorget,  and  by  making  the  two 
hands  feel  each  other,  prepares  them  for  co-operating  in  the 
most  critical  moment  of  driving  in  the  gorget ;  and  when  all  is 
prepared  tor  driving  home  the  gorget  into  the  bladder,  the  sur- 
geon depresses  the  handle  of  the  staff,  so  as  to  carry  the  point 
of  it  deep  into  the  cavity  of  the  bladder  ;  his  staff  stands,  at 
this  moment,  at  right  angles  with  the  patient's  body  ;  he  rises 
from  his  seat,  stands  over  the  patient,  for  an  instant  of  time, 
balancing   the  staff  and  gorget  once   more,  and,  feeling  once 

*  I  intreat  thofe  who  are  not  perfe&ly  confident,  to  make  their  incifion  of  the 
urethra  more  than  halt  an  inch  in  length  ;  an  incifion  ot  halt  an  inch  in  length  is  jufl 
futficient  to  be  dillincftly  felt,  and  to  allow  the  beak  of  the  gorget  to  be  fairly  intro- 
duced ;  but  it  is  an  incifion  whi<_h  a  furgeon  uuaccultomed  with  operation  might 
lofe  and  full  into  coniufion.  I  advife  him  rather  to  flit  up  nearly  the  whole  length 
of  the  membranous  part  of  the  urethra,  when  his  incifion  will  be  nearly  an  inch 
:n  length. 


Of  extracting  the  Stone.  1 83 

more  that  the  beak  is  fairly  in  the  groove,  he  runs  it  home  in- 
to the  bladder,  pointing  it  r.ither  upwards,  than  directly  back- 
wards :  then  the  urine  gushes  out  ;  the  beak  of  the  gorget 
goes  off  from  the  point  of  the  staff  with  an  audible  cluck,  and 
the  operator  withdraws  the  staff  with  the  lelt  hand,  as  the  con- 
clusion of  that  movement  with  which  he  drives  in  the  gorget 
with  the  right. 

Of  extracting  the  Stone. 

The  moment  the  gorget  is  driven  home,  as  it  always  is,  up 
to  the  hilt,  (the  thumb  of  the  operator,  which  lies  upon  the 
gorge  of  the  instrument,  being  actually  within  the  wound,) 
the  fundus  of  the  bladder  is  in  danger, — for  the  horrid  and  un- 
natural feeling  of  being  thus  impaled  excites  the  patient  to  prtss 
downwards,  as  in  passing  the  laei  es  and  urine  ;  the  bowels  are 
forced  down  upon  the  bladder  ;  the  lundus  of  the  bladder  is  for- 
ced, by  this  pressure  from  above,  and  its  own  natural  contrac- 
tions, upon  the  edge  of  the  instrument  ;  matters  stand  now  in  a 
very  dangerous  condition,  and  the  best  means  of  preventing 
harm,  is  to  introduce  the  forceps  quickly  !  no  time  should  be 
lost  in  the  foolish  ceremony  of  introducing  the  fore-finger  to 
feel  for  the  stone  !  Those  who  use  only  the  knife,  use  the  finger 
as  a  conductor  for  the  forceps  ;  but  those  who  use  the  gorget  as 
a  conductor  for  the  forceps  cannot  feel  the  stone  with  the  finger, 
for  it  lies  under  the  gorget,  and  the  gorget  exceeds  the  length 
of  two  fingers. 

The  moment  the  gorget  is  thrust  home,  the  operator  with- 
draws the  staff,  and  gives  it  away  ;  takes  the  handle  of  the  gor- 
get with  the  lelt  hand,  and  the  forceps  in  the  right  ;  the  chops 
of  the  forceps  being  close,  he  passes  them  along  the  channel  of 
the  gorget,  and  the  moment  the  right  hand  has  introduced  the 
forceps,  the  left  hand  withdraws  the  gorget.  Then  the  opera- 
tor, taking  the  handles  of  the  forceps,  one  in  each  hand,  be- 
gins to  feel  for  the  stone  ;  the  iorceps  must,  by  passing  along 
the  gorget,  inevitably  pass  over  the  stone  ;  let  him,  therefore, 
taking  the  two  handles  of  the  forceps,  one  in  each  hand,  stand 
high  above  his  patient,  point  his  forceps  downwards  towards 
the  bottom  of  the  pelvis,  to  that  sac  or  bulging  of  the  bladder, 
in  which  the  stone  usually  lies,  and  there  he,  in  nine  of  ten 
cases,  will  encounter  the  stone  ;  if  he  feels  it  with  the  forceps 
and  cannot  seize  it,  it  is  because  he  has  passed  over  it,  and 
touches  it  only  with  the  lower  side  of  one  of  the  chops.  When 
he  feels  that,  he  presses  the  stone  with  the  point  of  the  forceps, 
he  then  opens  the  blades  with  both  hands,  grasps  the  stone,  tries 
the  hold  he  has  of  it  in  a  way  which  it  is  impossible  to  describe, 


184  Of  the  causes  of  the  Slipping  of  the  Gorget. 

then,  by  grasping  very  firmly  with  the  right  hand  at  the  extre- 
mity of  the  handles,  lie  holds  the  stone  firm,  and  by  laying  the 
left  hand  on  the  forceps,  and  holding  with  it  also,  he  assists  the 
right,  confirms  the  hold,  and  prevents  at  the  same  time  (by 
slipping  his  left  fore-finger  into  the  hinge)  any  undue  pressure, 
such  as  a  soft  stone  will  not  easily  bear.      Having  thus  fixed  his 
hands,  he  begins  to  pull ;  and  if  the  stone  be  small  and  the  inci- 
sion free,  it  comes  easily  and  smoothly  along.      But  I  have  ob- 
served that  the  young  surgeon,  when  he  feels  the  slightest  op- 
position, expects  to  succeed  by  turning,  twisting,  and    every  I 
kind  of  unmeaning  violence,  and  has  no   absolute  rule   for  a 
stage  of  the  operation,  which  should  yet  be  performed  with  an 
intention  and   manntr  as  determined  as  any  other.     If  the  sur- 
geon holds  firmly  and  pulls  in  one  uniform_direction,  though  he 
had  the  strength  of  a  Cyclops,  he  could  not  succeed  ;  if  he  turns 
and  twists  his  forceps  from  side  to  side,  u  this  way  and  that  way, 
Ca-et-Ia,"  as  if  he  were  dilating,  not  extracting,  according  to  the 
directions  of  Paraeus,  since  he  is  pulling  without  any  design,  he 
still  has  but  little  chance  to  succeed.      If  he  will  but  reflect  on 
the  operation  of  the  forceps,  that  the  forceps  are  two  levers  with 
which  he  is  to  act  alternately,  depressing  first  one  side  of  the 
stone,  then  the  other,  he  will  not  scruple  to  adopt  that  decisive 
manner  in  extracting,  which,  though  it  seems  harsh,  is  really 
easy,  and  relieves  his  patient  the  most  speedily,  and  with  the 
least  violence.     Let  him,  after  having  seized  the  stone  fairly, 
press  the  handles  of  his  forceps  first  down,  then  raise  them  up, 
then  depress  them  again,  with  a  wide  and  free  motion,  and  he 
wiil  be  sensible,  that  by  this  slow  and  equable  motion,  the  parts 
are  little  bruised  by  the  cheeks  of  the  forceps,  and  the   stone 
will  be,  in  a  few  strokes,  brought  to  the  mouth  of  the  wound, 
and  turned  out,  by  one  wide  but  gentle  movement,  into  the 
left  hand  of  the  surgeon,  which  is  held  with  the  palm  upwards 
ready  to  receive  it.* 

section  v. 

Of  the  causes  of  the  Slipping  of  the  Gorget. 

It  wiil  be  easily  perceived  that  the  critical  movement  on 
which  the  fate  of  the  patient  depends,  is,  the  cutting  the  ure- 
thra, the  lodging  the  beak  of  the  gorget  in  the  groove  of  the 
staff,  and  the  driving  home  the  gorget.  In  attending  opera- 
tions, I  have  observed,  in  this  moment,  such  a  degree  of  hesi- 

*  If  the  ftonc  be  large,  it  will  be  obftructed  by  the  arch  of  the  pubis,  un- 
lefs  the  operator  pref9  downwards  towards  the  rctftuni :  this  muft  be  particu- 
larly attended  to  in  women.    S. 


Of  the  causes  of  the  Slipping  of  the  Gorget.  185 

tation  and  evident  alarm  on  the  part  of  the  operator,  as  convin- 
ces me  that  it  is  a  most  important  duty  to  explain  the  va- 
rious causes  of  the  gorget  slipping  off  from  the  groove  of 
the  staff :  he  will  best  guard  this  accident,  who  is  aware  of 
every  possible  cause :  it  proceeds,  like  every  important  error, 
from  want  of  knowledge  in  anatomy  :  since  we  often  see  the 
surgeon  seeking  the  femoral  artery  for  an  hour,  to  tie  it  in  a 
sound  thigh,  (the  aneurism  being  in  the  ham,)  we  need  not 
wonder  if  such  an  executioner  mangle  the  urethra  in  attempt- 
ing to  perform  lithotomy,  and  conclude  with  thrusting  his  gor- 
get betwixt  the  bladder  and  the  rectum. 

1st,  It  sometimes  happens,  that  the  surgeon,  deceived  by  the 
common  description,  and  expecting  to  cut  his  incisions  fairly 
upon  the  bend  of  the  staff,  goes  deep  into  the  hollow  of  the 
pelvis,  and  yet,  after  much  dissection,  feels  no  staff;  falling 
then  into  confusion,  and  anxious  to  be  relieved  from  this  dis- 
tressing scene,  he  begins  to  believe  that  he  must  somehow  have 
cut  the  urethra,  and,  believing  this,  he  at  a  venture  thrusts  in 
his  gorget :  sometimes  the  surgeon,  having  felt  the  staff,  and 
distinguished  the  membranous  part  of  the  urethra,  and  turned 
up  the  knife,  cuts  into  the  groove  with  so  tremulous  a  hand  that 
he  hardly  wounds  it ;  and  having  failed  to  dissect  the  urethra 
naked,  before  making  this  incision,  the  fibres  of  the  levator-ani 
muscle  close  upon  the  small  slit  which  he  had  made  in  it,  and 
thus,  after  feeling  distinctly  the  groove  of  the  staff,  he  loses  it 
again,  and  his  gorget  passes  betwixt  the  bladder  and  the  rec- 
tum. 

2dly,  Confusion  and  alarm,  in  the  simple  business  of  cutting 
the  urethra,  is  a  sure  indication  that  the  surgeon  is  in  danger 
of  doing  something  very  terrible.  Often  you  will  observe  the 
surgeon,  in  place  of  turning  up  his  knife  at  once,  and  striking 
it  steadily  and  firmly  into  the  groove  of  the  staff,  lay  down 
the  knife,  and  lift  it  alternately  several  times  ;  first  he  be- 
lieves that  he  has  cut  the  urethra,  and  then  again  becomes 
sensible,  either  that  he  has  not  cut  it,  or  that  he  has  lost  the 
small  slit  that  he  had  made.  I  have  seen  the  operator  give 
away  the  knife,  receive  the  gorget  from  the  assistant,  point  it 
at  the  groove  of  the  staff,  and  try  to  introduce  it,  resume  the 
knife,  and  make  new  incisions  in  the  urethra,  five  or  six  suc- 
cessive times.  I  have  seen  the  gorget  driven  twice,  not  into 
the  bladder,  but  deep  among  the  bowels,  for  although  there 
was  a  stone,  the  surgeon  never  reached  the  bladder,  never  one 
drop  of  urine  flowed,  the  stone  was  not  extracted,  and  the  boy 
died ;  this  last  mistake  is  mere  butchery  ;  the  first  is  little  short 
of  it,  for  if  every  time  that  the  surgeon  resumes  the  knife,  he 
has  lost  his  first  incision  and  makes  a  new  opening  in  the  lire? 

2  A 


186  Of  the  causes  of  the  Slipping  of  the  Gorget. 

thra,  if  every  tim.j  that  he  loses  one  incision,  the  urethra  has 
turned  in  some  slight  degree  upon  the  staff,  before  he  makes 
another,  the  successive  incisions  will  almost  entirely  separate 
the  urethra  from  the  bladder,  and  the  slightest  push  of  the  gor- 
get will  drive  off  the  gland  from  the  urethra. 

3dly,  There  is  much  too  in  the  direction  in  which  the  gorget 
is  driven  forward,  for  though  the  urethra  be  fairly  cut,  yet  the 
angle  at  which  the  staff  is  ht  Id,  or  manner  in  which  the  beak 
of  the  gorget  is  laid  to  the  groove  of  the  staff,  mav  disappoint 
the  surgeon  of  his  purpose,  and  make  the  gorget  shoot  past  the 
bladder  or  push  off  the  gland  from  the  urethra.  If  the  handle 
of  the  staff  be  too  much  depressed,  so  as  to  turn  its  point  high 
up  towards  the  fundus  of  the  bladder,  while  the  gorget  is  point- 
ed too  low  towards  the  rectum,  the  gorget,  in  place  of  enter- 
ing^moothly,  will  start  off  from  the  staff:  or  if,  on  the  other 
hand,  the  handle  of  the  staff  be  held  too  high,  is  too  near  the 
groin,  too  much  in  its  first  position,  and  the  gorget  pointed 
much  upwards,  the  directions  of  the  groove  and  the  beak  of  the 
gorget  will  not  correspond;  the  cutting  edge  of  the  gorget  will 
not  be  so  directed  as  to  cut  its  way  forward  ;  the  beak  will  hitch 
against  the  point  of  the  gland,  and  may,  especially  if  the  ure- 
thra be  mangled,  force  off  the  neck  of  the  bladder  and  prostate 
from  the  urethra. 

4thly,  The  surgeon,  in  place  of  moving  the  gorget  along  the 
groove  of  the  staff,  sometimes  allows  both  gorget  and  staff  to 
go  together  deeper  into  the  bladder,  till  they  touch  its  fundus  ; 
sometimes  the  operator,  by  an  awkwardness  in  the  posture  of 
the  gorget,  needs  to  use  such  force,  that  the  gorget,  when  it 
starts  through  the  first  obstruction  at  the  neck  of  the  bladder, 
may,  (especially  in  a  contracted  bladder)  wound  the  fundus. 
Even  the  forceps,  blunt  as  they  are,  may,  bv  rudeness  and  ig- 
norance, be  driven  through  the  fundus  of  the  bladder,  the 
stone  escaping  by  the  rent,  where  the  forceps  cannot  follow  it, 
into  the  cavity  of  the  abdomen.  Those  who  prefer  the  gorget, 
and  regard  it  as  the  ultimate  improvement  of  this  operation, 
avow  these  facts.  u  I  have  more  than  once  (says  Earle)  known 
a  gorget,  though  passed  in  a  right  direction,  pushed  on  so  far 
and  with  such  violence,  as  to  go  through  the  opposite  side  of  the 
bladder." 

5thly,  If  the  staff  be  short  and  the  assistant  unskilful  in  the 
management  of  it,  he  may,  alter  the  surge  on  has  cut  the  ure- 
thra, allow  the  staff  to  recede  from  the  bladder,  and  in  thrusting 
it  back,  push  its  point  not  home  again  into  the  bladder,  but  out 
through  the  wound  in  the  urethra !  The  staff  being  thus 
lodged  betwixt  the  rectum  and  bladder,  the  gorget  must  follow 
it ;  the  surgeon  feels  the  groove  of  the  staff  quite  naked,  fixes 


Of  the  causes  of  the  Slipping  of  the  Gorget.  1 87 

the  beak  of  his  garget,  and  drives  it  home  in  the  true  direction, 
but  no  urine  Mows  !  upon  introducing  the  forceps,  he  feels  no 
stone  !  he  is  in  the  end,  after  much  violence,  obliged  to  put  his 
patient  to  bed  to  die.  Such  an  accident  is  recorded  by  Mr. 
Earle,  it  proves  the  dangers  of  this  particular  operation  with 
the  gorget,  and  the  superiority  oi  that  with  the  kmie  ;  the 
plunge  of  the  gorget,  to  those  who  know  how  toopt rate  only  with 
the  gorget  is  irremediable,  but  a  surgeon  perfectly  acquainted 
with  the  parts,  and  skilled  in  dissection,  would,  in  such  a  case, 
introduce  his  ringer,  feel  for  the  prostate,  strike  his  knife  into 
it,  and,  putting  in  his  finger,  guide  the  forceps  into  the  bladder, 
and  at  least  extract  the  stone,  if  not  save  the  patient.  Chessel- 
den  once  performed  this,  when  another  operator  had  tailed, 
and  pushed  his  instruments  betwixt  the  bladder  and  rectum. 

6thly,  Though  the  gorget  has  passed  right,  the  forceps  may 
be  directed  wrong,  for  after  a  first  attempt  at  extraction,  and 
when  the  forceps  have  slipped,  the  scoop  or  finger  are  intro- 
duced, and  the  forceps  re-entered  ;  but,  the  opening  which  the 
gorget  makes,  does  not  very  easily  admit  tht  forceps,  even  when 
the  gorget  lies  in  the  wound,  to  guide  them  ;  after  the  gorget  is 
withdrawn,  the  forceps  enter  with  greater  difficulty,  the)  slip 
more  easily  in  among  the  loose  cellular  substance  of  the  rectum. 
The  operator  opens  the  forceps,  and  feels  in  vain  for  the 
stone  ;  he  at  last  has  an  indistinct  perception  of  the  stone, 
closes  them  upon  it,  grasps  it,  and  begins  to  pull ;  but  the  for- 
ceps slip  ;  the  bladder  is  betwixt  tht  stone  and  the  forceps. 
These  are  the  true  sacculated  stones,*  but  the  sac  is  the  bladder 
and  the  cavity  is  that  whieh  is  made  among  the  cellular  sub- 
stance of  the  rectum,  by  the  turning  of  the  forceps  in  search  of 
the  stone,  and  the  opening  their  blades  violently  to  grasp  it.  In 
one  unfortunate  case,  the  surgeon  groping  thus  upon  the  outside 
ot  the  bladder,  actually  grasped  with  the  point  of  his  forceps, 
and  twisted  away  the  great  part  of  the  prostate  gland,  which, 
when  he  had  thrown  it  down  among  his  feet,  was  picked  up 
by  a  professor  of  anatomy  who  assisted  at  the  operation,  and, 
when  the  gentleman  died,  the  parts  were  dissected  out,  and  are 
preserved. 

It  is  unquestionable  that  the  gorget  is  often  thus  plunged 
among  the  viscera,  and  perhaps  it  is  to  be  lamented  that- ever 
cutting  for  the  stone  ceased  to  be  a  distinct  profession,  or  that 
the  operation  was  brought  to  that  kind  of  perfection  which  in- 
duced ignorant  men  to  venture  upon  an  operation,  which,  even 
thus  simplified,  requires  consummate  skill  and  knowledge. 
Whatever  may  be  the  apparent  facility  of  this  common  operation 
with  the  gorget,  that  with  the  knife  is  alone  secure,  it  is  indeed 

There  are  inftanccs  of  (tones  contained  in  facs :  I  have  feen  a  preparation  of 
one  :  the  circumftano.'  is  probably  rare.     S. 


188  Of  the  Operation  of  Lithotomy, 

to  the  last  degree  simple,  as  simple  as  that  of  cutting  on  the 
gripe ;  for  it  is  cutting  with  the  knife  upon  the  staff,  which  is 
more  easily  held,  fixed,  and  directed,  than  the  stone.  But 
since  the  operation  with  the  gorget  has  been  approved,  and 
will  continue  to  be  performed,  I  have  taught  it  faithfully  ;  no- 
thing can,  in  my  opini6n,  so  well  prepare  the  young  surgeons 
against  this  fatal  accident,  the  slipping  of  the  gorget,  as  knowing 
perfectly  the  causes  from  which  it  may  arise.  And  I  will  now 
fulfil  my  purpose  of  describing  the  several  acts  and  stages  of 
the  operation  in  that  rapid  succession  in  which  they  should  be 
performed.* 

SECTION    VI. 

Of  the  Operation  of  Lithotomy. 

An  operation  so  mechanical  as  this,  regulated  in  its  most 
critical  movement  by  a  grooved  staff,  should,  though  there 
must  be  no  unbecoming  haste,  proceed  rapidly  without  a  pause, 
the  several  acts  being  connected  in  idea,  and  continuous  in  ex- 
ecution. The  surgeon  should  never,  to  catch  the  vain  applause 
of  the  ill-judging  spectators,  proceed  in  haste  and  trepidation  ; 
but  he  who  can  perform  the  operation  at  all,  will  perform  it  best 
to  his  feeling,  and,  for  the  safety  of  the  patient,  rapidly  ;  for,, 
having  the  purpose  of  the  operation  full  in  his  mind,  its  several 
stages  are  as  parts  of  one  continued  action,  on  which  his  mind  is 
so  intent,  his  judgment  so  clear  and  unperplexed,  his  hand  so 
steady  and  resolved,  that  he  moves,  by  a  sort  of  instinct,  with- 
out pauses,  without  fear.  In  truth,  dexterous  and  rapid  execution 
are  synonymous  words ;  it  is  not  policy,  but  feeling  and  self-confi- 
dence, that  carries  the  surgeon  boldly  on  ;  this  rapid  energetic 
manner  is  natural  and  not  assumed  ;  it  is  even  in  some  degree 
esst  ntial  to  the  patient's  safety,  that  the  several  acts  should  suc- 
ceed each  other  without  stop  or  pause, — that,  the  gorget  should 
be  introduced  as  soon  as  the  urethra  is  cut, — and,  the  forceps 
instantlv  after  the  thrusting  in  of  the  gorget. 

The  surgeon  should  be  prepared  for  this,  and,  in  place  of 
receiving  and  returning  every  instrument  from  his  assistants, 
should  draw  each  instrument  from  his  girdle  when  he  is  to  use 

*  When  this  accident  happens,  which  may  be  always  known  from  not  hearing 
the  click  which  is  produced  by  the  flipping  of  the  beak  of  the  gorget  from  the  end 
of  the  groove  of  the  ftaff,  and  from  no  urine  flowing  upon  the  introduction  of  the 
gorget,  if  the  furgeon  has  not  withdrawn  the  ftaff,  which  he  never  fhould  do  un- 
til he  is  certain  che  gorget  is  in  the  bladder ;  he  fhould  withdraw  the  inftrument 
and  make  another  attempt  to  introduce  it ;  but  fhould  he  have  withdrawn  the 
ftaff,  the  patient  muft  be  unbound,  put  to  bed,  and  the  wound  fuffercd  to  heal  beforc- 
any  thing  farther  is  attempted.    fc>. 


Of  the  Operation  of  Lithotomy.     *  189 

it.  Every  thing  being  prepared,  he  ties  an  apron  about  him, 
which  being  firmly  girt,  he  twists  a  towel  through  the  apron- 
string,  fixes  the  gorget  also  in  the  string  like  a  dagger  in  the 
girdle,  and  the  forceps  he  puts  in  the  tore-pocket  of  his  apron. 
Then  advancing  to  the  patient,  who  is  tied  and  placed  for  ope- 
ration, though  his  posture  is  not  yet  adjusted,  he  dips  the  staff 
in  oil  and  passes  it  gently  and  softly  ;  he  then  dips  the  finger 
in  oil,  and  insinuates  into  the  rectum,  to  feel  that  alt  is  right 
and  fair ;  he  then  wipes  the  fingers  that  are  soiled  with  urine 
or  faeces,  or  lubricated  with  oil,  and  seats  himself  belore  his 
patient,  on  a  low  stool,  pulling  the  breech  towards  him,  till  it 
projects  fairly  over  the  edge  of  the  table,  and  pressing  in  the 
doubling  of  the  blanket  under  the  breech,  till  he  has  raised  it  to 
a  proper  angle  ;  he  then  commits  the  patient's  feet  to  the  lateral 
assistants,  who  are  to  keep  the  breech  in  this  suspended  posture : 
then  reaching  his  right  hand  over  the  patient's  breech,  he 
takes  a  firm  hold  on  the  handle  of  the  staff;  presses  its  heel 
against  the  perinsum  ;  feels  for  it  immediately  behind  the  scro- 
tum with  the  fore-finger,  or  with  the  edge  of  the  thumb;  lays 
down  the  handle  of  the  staff  to  the  right  groin,  and  gives  it  to 
the  assistant-surgeon  to  keep  it  steadv. 

He  now  wipes  the  perinseum  with  his  towel,*  lays  the  left 
hand  over  the  hip  and  anus,  and  spreads  his  fingers  so  as  to 
stretch  the  perineum  ;  then  fixing  the  point  of  the  knife  just 
below  the  point  where  he  feels  the  heel  of  the  staff,  (i.  e.  about 
an  inch  behind  the  scrotum)  and  pressing  with  the  point  of  the 
knife  to  mark  the  beginning  of  the  incision,  he  draws  it  with  a 
firm  and  steady  motion,  obliquely  downwards,  till  he  passes  the 
anus  about  an  inch  and  a  half,  the  middle  and  deepest  part  of 
the  incision  being  thus  opposite  to  the  anus,  but  inclining  some- 
what towards  the  tuber  ischii  to  avoid  the  rectum.  The  first 
stroke  of  the  knife  passes  through  the  skin  and  fat ;  a  second 
stroke,  guided  by  the  fore-finger,  passes  deep  into  the  hollow 
of  the  pelvis,  through  fat  tendinous  fascia,  and  the  transverse 
muscle,  and,  in  short,  through  every  obstruction,  till  tht  open- 
ing is  quite  free.  A  third  dissection,  in  which  the  fore-finger 
is  turned  upwards  to  the  pubis,  while  the  ring  and  mid  fingers, 
a  little  crooked,  repress  the  rectum,  lays  the  staff  almost  bare ; 
and  then,  the  edge  of  the  knifi-  also  turned  upwards,  as  well  as 
the  finger  which  guides  it,  is  struck  into  the  groove  of  the  staff, 
through  the  membranous  part  of  the  urethra  ;  and  the  knife, 
being  then  drawn  steadily  forwards,  slits  it  up  from  the  point 

•  The  re&um  generally  protrudes  in  a  child,  from  crying  and  ungovern=d 
ftraining,  and'  needs  to  be  wiped  and  held  afidc  by  a  bit  of  linen  cloth  hid 
upon  it. 


190  Of  the  Operation  of  Lithotomy. 

of  the  prostate   gland  nearly  to  the  bulb  of  the  urethra,  i.  e. 
through  almost  the  whole  length  of  the  part  that  feels  naked. 

The  edge  of  the  thumb-nail  being  fixed  steadily  in  the  groove 
of  the  staff,  the  beak  ot  the  gorget  is  lodged  in  the  groove  ;  the 
surgeon,  first  moving  the  gorget  backwards  and  forwards, 
reaches  his  leit  hand  over  to  grasp  ihe  staff,  takes  a  firm  hold 
of  it,  rises  from  his  seat,  balances  with  the  two  hands  lor  a  few 
instants,  and  feeling  that  the  instruments  correspond,  that  the 
hands  feel  each  other,  and  re-act  mutually,  and  that  the  btak  of 
the  gorget  gl  des  smoothly  and  equably  in  the  groove  of  the 
staff,  he  holds  the  staff  steady,  clenched  in  a  dagger-like  man- 
ner, in  his  lelt  hand,  and  pushes  the  gorget  steadily,  strongly, 
but  slowly,  forward  with  his  right  Ihe  moment  that  he  feels 
the  resistance  over,  and  the  urine  flow,  he  begins  to  give  that 
turn  to  the  staff  (viz.  depressing  the  handle  of  it  to  the  belly  of 
the  patient)  by  which  the  gorget  is  disengaged,  and  the  staff 
withdrawn  ;  he  slips  the  staff  into  his  pouch,  or  lays  it  down, 
seizes  the  handle  of  the  gorget  with  the  left  hand,  draws  out 
his  forceps  with  the  right,  lays  tht  chops  of  them  gently  in  the 
broid  channel  of  the  gorget,  pushes  them  gently  onwards  into 
the  bladder,  and  when  he  feels  them  in  the  open  cavity,  he 
withdraws  the  gorget,  withdrawing  it  carefully  in  the  direction 
in  which  it  was  pushed  in,  that  its  edge  may  make  no  second 
wound. 

The  staff  is  withdrawn  as  a  part  of  the  same  motion  by  which 
the  gorget  is  introduced  ;  the  gorget  is  withdrawn  as  a  part  (the 
concluding  part)  of  the  same  motion  with  which  the  forceps  are 
introduced  ;  the  gorget  is  next  slipped  into  the  pocket  of  the 
apron,  and  both  hands  applied  to  the  forceps,  one  to  each  han- 
dle ;  and  the  operator,  conscious  that  the  forceps  now  look  di- 
rectly upwards  towards  the  fundus  of  the  bladder,  where  the 
stone  cannot  be,  and  that  the  gorget  has  carried  thtm  over  the 
stone,  raises  the  handles  high,  and  while  he  opens  the  blades 
gently,  points  them  downwards  to  the  sac  behind  the  prostate, 
and  near  the  neck  ot  the  bladder  where  the  stone  lies;  and  he 
withdraws  them  at  the  same  time  a  little,  that  they  may  have 
the  stone  before  them  :  he  then  pushes  the  stone  before  him, 
and  thus  excites  the  bladder  to  contract,  and  press  it  close  to 
the  chops  of  the  forceps  ;  he  closes  them,  and  presses  once  or 
twice  in  directions  sightly  varied,  according  to  feelings  which 
cannot  be  described,  before  he  thinks  himself  sure  of  his  hold  ; 
but  when  he  is  sure,  he  grasps  firmly,  very  firmly,  because,  it 
the  stone  be  so  large  as  to  endanger  its  breaking,  he  is  more  will- 
ing that  it  should  break  into  a  hundred  pieces  than  injure  the 
parts  by  dilatation ;  and  he  now  depresses  the  handles  quite  low, 
because  the  direction  in  which  he  is  to  extract  the  stone,  is  en- 


Of  the  Operation  of  Lithotomy,  191 

tirely  opposite  to  that  in  which  he  catches  it.  The  forceps, 
holding  the  stone,  now  point  directly  upwards,  as  at  first :  he 
holds  firm,  and  pulls  almost  directly  downwards,  that  the  pres- 
sure may  be  not  against  the  pelvis,  but  against  the  dilatable 
parts  in  the  lower  angle  ot  the  woand  ;  and  moving  his  forceps 
gently,  slowly,  steadily,  from  side  to  side,  with  a  very  wide 
motion,  he  depresses,  first,  the  upper  side  of  the  stone,  then  the 
lower  side,  and  so  alternately,  till  the  widest  parts  of  the  chops 
stretch  the  wound  :  the  stone  begins  to  appear  ;  he  holds  the 
palm  of  the  left  hand,  which  had  hitherto  held  firm  the  hinge 
of  the  forceps,  so  as  to  receive  the  stone ;  and  with  one  wide 
motion  ol  the  forceps  moving  the  handles  largely  downwards, 
he  turns  it  out. 

If  the  perinaeal  artery,  which  is  unavoidably  wounded,  is 
large,  and  bleeds  profusely,  it  is  usually  tied  with  the  needle 
after  the  external  incision,  and  before  the  urethra  is  cut.  If 
the  haemorrhagy  be  neglected  till  the  operation  is  finished,  the 
arteries  are  then  so  bruised,  and  so  retracted  among  the  cellu- 
lar substance,  that  they  never  bleed  again ;  if  there  be  any  in- 
ternal haemorrhagy  from  arteries  larger  than  common,  coursing 
round  the  prostate  gland,  and  cut  with  the  gorget,  it  is  disco- 
vered only  some  hours  after  the  patient  is  laid  in  bed  ;  it  is 
known  by  the  desire  to  pass  urine,  the  sense  of  load  at  the  low- 
er part  of  the  abdomen,  and  restlessness  and  pain  ;  and  it  is  re- 
lieved by  pushing  in  the  finger,  and  breaking  down  the  coagula, 
which  are  then  discharged  as  from  the  uterus  in  an  abortion, 
and  then,  if  fresh  blood  continues  to  flow,  farther  dangc  r  is  pre- 
vented by  thrusting  a  wide  canula  into  the  wound,  surrounded 
with  a  piece  of  dried  sponge,  the  canula  being  passed  through 
a  hole  in  the  centre  of  the  sponge."* 

The  stone  being  extracted,  the  surgeon,  having  examined 
and  assured  himself  that  there  is  no  second  stone,  lavs  a  piece 
of  oiled  lint  within  the  lips  of  the  wound  ;  unbinds  the  patient, 
and  lays  his  thighs  together,  the  knees  being  bended,  and,  an 
assistant  holding  his  hand  flat  over  the  wound  ;  and  the  patient 
is  conveyed  to  bed,  and  laid  on  his  right  side.  An  opiate  is 
given  with  a  glass  of  warm  wine  and  water  ;  the  curtains  are 
drawn,  the  windows  closed,  and  a  medical  attendant  being  left 
by  him  to  watch  any  accession  of  haemorrhagy,  or  abdominal 
pain,  he  is  composed  to  rest  ;  the  urine  which  flows  freely 
through  the  wound  is  received  upon  a  thick  folded  cloth.     The 

*  If  the  internal  pudic  artery  be  divided,  which  it  fometimes  is,  particularly 

when  Mr.  Oline's  fnigle-edged  gorget  is  uied,  it  may  be   reftraincd ;  for  I  have, 

feen  it  done,  by  introducing,  after  the  operation  is  concluded,  a  large  dofiil  of  lint, 

and  preffing  it  firmly  for  fome  minutes  againfl  the  artery ;  fhould   however  thi* 

nfw.cr,  the  veffel  may  be  tied.     S. 


192  Of  introducing  the  Catheter. 

warm  bath,  clysters,  bleeding,  if  he  be  an  athletic  man,  and  em- 
brocating the  lower  part  of  the  belly  with  spirituous  applications, 
are  the  chief  means  lor  preventing  abdominal  inflammation. 

I  hope  that,  in  preparing  my  reader  for  understanding  this 
description,  I  have  with  proper  seriousness  inculcated  the  im- 
portance of  study,  and  the  fatal  consequence  of  imitating,  with- 
out intelligence  or  design,  the  motions  of  other  operators  ;  that 
I  have  not,  by  any  presumption  on  my  part,  incited  the  young 
surgeon  to  anv  rash  or  unpremeditated  attempt  or  new  exploit, 
but  have  described  perspicuously,  simply,  and  with  a  sincere 
sense  of  duty,  the  most  important  and  eventful  operation  in 
surgery.        ' 


DISCOURSE  XIIL 


OF  OBSTRUCTION  OF  URINE. 


SECTION   I. 

Of  introducing  the  Catheter. 

X  HE  operation  of  introducing  the  catheter,  if  it  do  not  re- 
quire intrepidity  and  courage,  requires  at  least  peculiar  deli- 
cacy, a  perfect  knowledge  of  the  parts,  and,  above  all,  a  humane 
and  steady  temper;  for  when  the  surgeon  is  at  any  time  con- 
scious that  he  is  in  danger  of  committing  violence,  he  must 
submit  to  the  imputation  of  having  failed,  even  at  the  risk  of 
his  reputation.  Tht  obstacles  and  difficulties  to  the  introduction 
of  the  catheter  are  besides  of  so  peculiar  a  kind,  that  while  all 
our  diligence  to  learn  this  art  is  necessary,  our  utmost  dili- 
gence is  sometimes  unavailing,  ior  the  most  unskilful  surgeons 
have  succeeded,  by  a  sort  of  chance,  even  after  the  most  dex- 
terous have  failed. 

There  are  no  circumstances  in  which  the  patient  is  more  per- 
fectly grateful,  than  for  the  relief  which  the  skilful  introductio* 


Of  Introducing  the  Catheter.  193 

of  the  catheter  procures  ;  for  it  is  a  sudden  and  entire  relief, 
from  anguish  more  excruciating  than  any  description  of  pain. 
Often  the  value  of  our  assistance  is  enhanced  by  the  unsuccess- 
ful attempts  of  others  less  fortunate  or  less  skilful.  To  feel  tnis 
uneasiness  and  intense  desire  to  pass  the  urine,  to  submit  to  a 
dreaded  operation,  and  yet  to  be  disappointed  of  relief  ;  to  see 
the  blood  streaming  from  the  penis,  and  still  to  continue  in  ago- 
ny ;  to  lie  tossing  with  fever  and  pain,  aggravated  by  dismal 
recollections  of  many  having  died  of  obstruction  of  urine  ;  and 
then  in  the  midst  of  these  sufferings,  to  receive  sudden  relief, 
from  the  hands  of  a  skilful  man,  must  be  accompanied  with  a 
deep  sense  of  gratitude.  Such  reflections  as  these\  my  reader 
will  not  think  unnatural.  I  would  condescend  to  suggest  even 
selfish  motives,  to  the  few  who  are  born  to  feel  no  others,  as  in- 
ducements to  study  those  diseases  of  which  I  am  no\v»to  offer  a 
short  practical  sketch  ;  I  should  be  inclined  to  blame  the  sur- 
geon very  much,  who  was  not  equally  prepared  to  use  the  ca- 
theter as  to  use  the  lancet. 

The  introduction  of  the  catheter  is  an  operation  which  a  good 
surgeon,  who  is  able  to  perform  with  ease,  would  be  apt  to  de- 
scribe with  little  care  or  minuteness  ;  and  there  is  unfortunately 
in  this,  if  any  part  of  surgery,  a  kind  of  address  which  is  to  be 
attained  only  by  practice.  Yet  this  experience  and  acquired 
dexterity  is  founded  on  previous  knowledge  of  the  parts.  I 
shall  give,  as  the  first  and  most  simple  lesson  in  this  depart- 
ment of  surgery,  that  of  introducing  the  catheter,  in  cases  where 
the  urine  is  retained,  not  from  any  resistance  arising  from  tu- 
mour or  other  obstruction  in  the  urinary  canal,  but  from  para- 
lysis or  mere  want  of  power  in  the  bladder  itself. 

When,  from  remaining  too  long  in  ceremonious  companies, 
in  assemblies,  in  processions,  or  in  courts  of  justice  ;  when, 
from  travelling  in  public  carriages,  or  from  any  cause  of  delica- 
cy or  restraint,  a  man  resists  too  long  the  calls  of  nature,  the 
bladder  being  over-distended,  loses  its  contractile  power,  and 
when  he  would  pass  his  urine  he  nukes  vain  and  painful  efforts 
to  discharge  it :  a  spasm  about  the  neck  of  the  bladder  then  a- 
rises,  and  resistance  is  added  to  want  of  contractile  power;  eve- 
ry repeated  effort  increases  the  difficulty,  and  pain  succeeds  to 
the  simple  desire  of  emptving  the  bladder.  It  is  this  pain  and 
spasm  alone  that  prevents  the  catheter  passing  with  perfect  ease, 
and  makes  all  the  opposition  we  experience  in  performing  that 
operation  on  the  living  body,  which  is  so  easily  performed  on 
the  dead  ;  for,  the  introducing  the  catheter  in  a  corpse,  is  not 
a  lesson  of  that  importance  which  has  usually  been  supposed. 

The  catheter  passes  with  perfect  ease,  when  the  retention  of 
urine  proceeds  from  a  paralytic  affection  of  the  bladder,  as  in 

I  H 


194  Of  Introducing  the  Catheter. 

fractures  of  the  spine,  in  palsy  or  apoplexy,  in  confluent  small- 
pox, in  the  end  of  low  levers.  Even  in  cases  when  strangury 
and  pain,  accompanied  with  intense  desire,  have  followed  the 
simple  retention  ot  urine  ;  in  cases  when  the  canal  is  generally 
inflamed,  as  in  gonorrhoea,  the  surgeon  should  still  be  able  to 
pass  the  catheter  with  toh  ra'ole  ease.  But  in  cases  ot  stricture, 
or  other  disease  in  the  urethra,  the  catheter  is  seldom  useful  ; 
and  where  the  prostate  gland  is  diseased,  it  passes  with  the  ut- 
most difficulty,  if,  indeed,  it  can  be  made  to  pass  by  any  means. 
You  proceed  in  the  following  manner  : 

You  place  >our  patient  with  his  back  resting  firmly  against 
the  wall,  striding,  but  not  very  wide,  his  feet  being  projected 
before  him  a  very  little;  and  you  place  yourself  on  his  left  side, 
kneeling  on  your  right  knee ;  you  may  lay  him  across  the  bed, 
his  feet  resting  on  the  floor,  his  buttocks  touching  the  edge  of 
the  bed,  and  his  head  and  shoulders  supported  with  the  pillows ; 
or  he  may  seat  himself  upon  a  chair,  resting  with  his  hands  up- 
on the  seat,  the  perinaeum  projecting  a  little  over  the  edge  of 
the  chair,  and  one  of  his  friends  standing  behind  to  support 
him.  In  whatever  posture  you  place  your  patient,  you  find  the 
posture  of  kneeling  on  the  right  knee  the  most  convenient  to 
yourself  ;  it  gives  you  perfect  steadiness  ;  and,  by  placing  your- 
self low  with  regard  to  the  patient,  you  obtain  a  perfect  com- 
mand of  your  catheter,  which,  while  you  are  introducing  it,  is 
to  move  in  a  circle. 

You  lift  the  point  of  the  penis  betwixt  the  fore  and  mid-fin- 
gers, securing  the  posture  of  the  penis  by  pressing  the  glans 
with  your  thumb  :  then  taking  the  catheter,  which  is  previously 
warmed,  and  smeared  with  oil,  white  of  eggs,  or  butter,  in  your 
right  hand,  \  ou  hold  it  firmly  by  the  ears,  betwixt  the  thumb 
and  fore- finger  ;  and  while  you  hold  by  the  wings  with  the  fin- 
gt  r  and  thumb,  you  lay  the  middle,  ring,  and  little  fingers,  flat 
across  the  shaft,  just  as  you  would  a  pipe.  You  then  apply  the 
point  of  the  catheter  to  the  opening  of  the  urethra,  and  glide  it 
down  steadily  and  rather  rapidly  along  the  urethra,  drawing  the 
penis  with  the  left  hand,  pressing  the  catheter  onwards  with  the 
right,  and  guiding  it  with  a  semicircular  sweep  round  the  pubis, 
in  proportion  as  the  catheter  passes  along  the  urethra.  The  two 
hands,  thus  re-acting,  the  catheter  glides  onwards  without  ob- 
struction, till  it  has  turned  round  the  pubis,  and  you  become 
sensible  by  the  turn,  by  the  length  it  has  passed,  and  by  the  de- 
gree of  resistance,  that  it  has  approached  the  neck  of  the  blad- 
der, and  is  just  about  to  enter  it. 

This  is  the  critical  moment,  in  which  may  be  seen  whether  a 
surgeon  can  or  cannot  pass  the  catheter  ;  for  if  he  knows  how 
to  pass  it,  he  suddenly,  but  not  violently,  changes  its  direction* 


Of  Introducing  the  Catheter.  195 

He  depresses  the  handle  with  a  particular  kind  of  address,  and 
raises  the  point,  which,  as  it  it  had  suddenly  surmounted  some 
obstacle,  starts  into  the  neck  of  the  bladder,  and  the  urine  bursts 
out  in  a  jet  from  the  mouth  of  the  catheter. 

Those  who  are  unskilful,  press  the  tube  forward,  and  persist, 
as  they  had  begun,  in  drawing  up  the  penis,  pulling  it  out  to  an 
immoderate  length,  imagining,  as  indeed  they  are  plainly  told, 
that  by  stretching  the  penis,  they  lengthen  the  urethra,  and  make 
it  straight,  whereas,  they  elongate  only  that  part  of  the  urethra 
along  which  the  catheter  has  already  passed. 

In  truth,  the  elongation  of  the  penis  does  not  at  all  affect  that 
part  of  the  urethra  at  which  the  catheter  is  interrupted,  the  part 
which  lies  in  the  perinaeum,  and  which  is  fixed  by  Various  con- 
nections :  a  dexterous  surgeon  indeed  generally  passes  the  cathe- 
ter with  one  continuous  motion  uninterrupted,  and  without  let- 
ting go  the  penis ;  but  when  he  does  feel  that  he  is  obstructed 
he  lets  go  the  penis,  ;»s  of  no  further  assistance;  he,  (while  his 
assistant  holds  up  the  scrotum,)  lays  two  fingers  along  the  peri- 
nasum,  on  each  side  of  the  urethra,  and  draws  the  fingers  along 
the  perineum  towards  the  scrotum,  soothing  the  parts,  and  re- 
laxing the  spasm,  by  the  pressure  and  motion^  and  acting  as  if 
the  design  were  to  work  the  urethra  along  the  catheter,  as  he 
would  put  the  bait  on  a  hook.  If  this  fail,  he  kneeling  before 
the  patient,  oils  the  left  fore-finger  and  passi  s  it  into  the  anus, 
the  effect  of  which,  is,  I  am  persuaded,  neither  the  elongation  of 
the  urethra,  nor  the  unfolding  any  inequalities,  of  the  canal,  but 
merely  lifting  up  the  point  of  the  catheter,  by  the  pressure  of 
the  finger,  and  with  a  degree  of  force  and  effect  which  the  sur- 
geon has  not  the  confidence  to  use  in  the  proper  way  of  bending 
down  the  handle  of  the  staff. 

From  the  moment  in  which  the  catheter  begins  to  pass  along 
the  perinaeum,  the  point  should  be  pressed  strongly  against  the 
upper  side  of  the  urethra  which  lies  under  the  pubis  ;  the  cathe- 
ter must  be  all  along  carried  so  close  to  the  arch  of  the  pubis,  as 
never  to  lose  the  feeling  of  pressing  hard  against  the  bone,  and 
when  it  approaches  the  neck  of  the  bladder  the  point  must  be  • 
turned  quick  under  the  arch  of  the  pubis,  as  if  it  were  the  sur- 
geon's intention  to  keep  it  pressed  close  to  the  inner  surface  of 
the  pubis.  While  the  surgeon  makes  the  point  run  thus 
along  the  bone,  as  if  to  avoid  the  angle  at  the  lower  part  of  the 
urethra,  he  must  guide  the  catheter  steadily  along,  holding  it 
firm  and  with  an  action  something  like  that  of  pulling,  as  if  it 
were  his  design  to  hook  the  pubis.  He  must  turn  down  the 
handle  and  raise  the  point  of  the  catheter,  I  will  not  say  sud- 
denly, or  strongly,  but  with  quickness  and  address,  as  if  it 
were  his  design  to  catch  at  some  orifice,  distinct  from  the  canal 


196  Of  Introducing  the  Catheter. 

in  which  the  instrument  is  passing,  and  to  catch  it  with  address 
and  quickness,  as  if  it  were  an  opening  which  might  otherwise 
escape. 

It  these  manoeuvres  do  not  succeed,  the  surgeon  changes  his 
catheter,  choosing  one  bigger  or  more  slender,  with  a   greater 
or  lesser  curve,  according  to  what  observations  he  may  have 
made  in  his  first  attempt;  but  if  the  catheter  has  been  of  a 
good  form  and  commodious  size,  yet  has  not  passed  easily,  he 
should,  instead  of  choosing  a  rigid  catheter  of  another  size  or 
form,  take  one  that  is  flexible  tor  his  second  attempt.     The 
flexible  catheter  is    generally  slender  and  of  sufficient  length, 
and  its  shape  may  be  accommodated  to  all  occasions,  and  to  all 
forms  of  the  urethra  ;  for,  having  a  stiff  wire,  we  can  give  that 
wire  (i-tther  before  or  after  it  is  passed  into  the  catheter)  what- 
ever shape  we  please  ;  and,  what  is  of  still  greater  importance, 
we  can  introduce  the  instrument  without  or  with  the  wire  as 
circumstances  may  direct ;  or  what  I  find  far  more  advantageous, 
we  can  introduce  the  wire  partially  so  as  not  quite  to  reach  the 
point  of  the  catheter,  but  within  two  inches  or  a  little  more  of 
the  point,  by  which  contrivance  the  point,  if  previously  warm- 
ed and  wrought  in  the  hand,  has  so  much  elasticity  that  it  fol- 
lows the  precise  curve  of  the  urethra,  and  has  yet  sufficient  rigi- 
ditv  to  surmount  any  slight  resistance.      If  this  too  fail,  and  es- 
pecially if  there  be  the  slightest  reason  to  suspect  that  the  resist- 
ance is  not  merely  spasmodic,  but  arises  from  stricture  near  the 
neck  of  the  bladder  in  the  young,  or  swelling  of  the  prostate  in 
the  aged,  we  take  a  small  bougie,  turn  up  the  extremity  of  it 
with  the  finger  and  thumb,  so  that  the  hooked  point  may   look 
towards  the  pubis,  oil  it  lightly  and  rapidly,  and  allowing  no 
time  for  the   softening  of  the  wax,  pass  it  into  the  urethra,  run 
it  down  nimbly  to  the  place  of  the  obstruction,  turn  it  with  a 
vertical  or  twisting  motion,  and  stick  it  fast  in  the  constricted 
part ;  and  having  left  the  bougie  thus  fixed  for  ten  minutes  or  a 
quarter  of  an  hour,  we  usually  find  upon  withdrawing  it,  (es- 
pecially it,  in  withdrawing,  we  feel  a  pull  as  if  it  would  invert 
the  urethra,)  that  either  the  urine  will  begin  to  flow,  or  at  least 
that  the  catheter  will  now  pass. 

But  when  we  •  are  unsuccessful  in  these  operations,  just  as 
when  we  fail  in  our  attempts  to  reduce  a  hernia,  we  resort  to 
other  means  of  relieving  the  stricture  of  the  parts,  before  ma- 
king a  second  attempt;  first  we  bleed,  bleed  repeatedly,  which, 
at  once  prevents  the  most  fatal  of  all  svmptoms,  inflammation 
of  the  abdomen,  and  serves  as  an  anodyne,  and  never  can  be 
superfluous  where  the  future  dangers  of  the  case,  and  in  some 
dt  gree  the  present  obstruction,  proceed  from  inflammation ; 
when  we  observe  the  condition  of  our  patient,  his  flushed  face. 


Of  Introducing  the  Catheter.  197 

parched  tongue,  and  rapid  pulse,  we  can  feel  no  reluctance  in 
bleeding.     We  immerse  the  patient  in  a  warm  bath,  and  rub 
the  pennajum  and  lower  part  ol  the  abdomen  with  stimulant 
embrocations,  as  spirituous  and  camphorated   balsams  or  oint- 
ments ;  we  lay   hot  and  stimulant  applications  to  the  pubis,  co- 
ver all  the  parts  with  a  thick  made,  poultice,  impregnated  with 
camphire  or  onions,  and,  above  all,  give  opiate  injections  very 
strong,  lor  we  find  this  the  most  effectual  means  of  alleviating 
the  pain  and  desire,  or  in  other  words,  the  spasmodic  action  of 
the  parts  :  it  is  spasm  merely  that  intercepts  the   catheter;  tor 
were  the   patient  dead,  no  such  opposition  would  be  experien- 
ced ;  innumerable  dissections  have    proved  that   the  catheter, 
\yhich  was  not  admitted  in  the  living,  passes  easily  into  the  dead 
body.     It  alter  a  few  hours  of  these  applications,  the  pain  is 
relieved,  and  the  patient,  by  the  force  of  the  opium,  is  inclined  to 
rest,  we  are  then  able  to  pass  the  catheter  with  ease  ;  and  when 
we  have  relieved  such  a  patient,  we  must  continue  our  attentions 
to   him   unremittingly  ;  we  give  him    prudent  advice  lest  the 
same  continued  life  of  thoughtlessness  and  dissipation  confirm 
the  complaint ;  we  charge  ourselves  with  drawing  off  the  urine 
thrice  a  day,  till  the  parts  recover  their  tone  ;  and  we  never  dis- 
miss such  a  patient  without  acquainting  him,  that  on  the  slight- 
est excess  or  imprudence,  he  will  relapse  into  this  paintul  condi- 
tion ;  for  the  bladder  once  distended  is  apt  to  be  again  distend- 
ed, without  creating   any  sensible  effort,  and,  being  over- dis- 
tended, it  loses  altogether  its  muscular  power. 

The  period  at  which  a  patient  will  recover  the  contractile 
power  of  his  bladder  must  depend  much  on  the  conduct  of  the 
surgeon,  who  will  be  able  to  restore  its  tone  by  being  careful  in 
his  attendance,  and  preventing  the  bladder  bring  at  any  time 
filled  ;  by  directing  the  patient  to  make  occasional  efforts  to 
discharge  his  urine,  even  although  not  incited  by  any  desire  ;  bj 
applying  stimulant  embrocations  to  the  pelvis ;  by  giving  stimu- 
lant and  purgative  injections,  or,  by  giving,  if  necessary,  a  few 
drops  of  tincture  of  cantharides  ;  and  finally  by  applying  blisters 
from  time  to  time  to  the  sacrum,  which  I  hold  to  be  the  most 
powerful  means  of  restoring  the  contractilitv  of  the  bladder  : 
along  vv-ith  these  means  the  walking  barefooted  on  a  stone  floor, 
or  having  cold  water  dashed  or  sprinkled  about  the  pelvis,  is 
very  effectual  in  seconding  the  efforts  ol  the  patient. 

If  in  introducing  the  catheter,  you  find  your  instrument  stop 
early  in  a  lower  part  of  the  urethra,  and  have  reason,  from  the 
history  of  the  case,  to  believe  that  the  obstruction  arises  from 
stricture,  you  must  not  persist    in    pressing  on  your  instru- 


198  Of  Introducing  the  Catheter. 

ment,  but  withdraw  it,  and  pass  a  small  bougie,  or  use  a  caus- 
tic* 

If,  in  passing  the  catheter,  you  encounter  a  stone,  which  you 
know  by  the  catheter  grating  against  it,  be  not  rash  to  drive  it 
back  into  the  bladder,  but  press  your  finger  upon  the  perinajum. 
behind  the  stone,  lest  it  should  be  driven  back, — withdraw  your 
catheter,  and  stop  to  consider  of  the  case,  and  the  means  of  giving 
safe  and  permanent  relief. 

But  if  from  the  age  of  your  patient  and  the  history  of  his 
complaint,  you  suspect  the  prostate  gland  to  be  diseased,  and 
especially  if,  from  introducing  your  finger  into  the  anus,  you 
are  assured  that  the  complaint  is  of  that  dismal  nature,  you 
may,  after  having  failed  in  the  common  way,  turn  the  concavity 
of  your  catheter  towards  the  perinseum,  and  turn  it  at  that 
point  of  your  progress  in  which  you  are  sensible  of  the  opposi- 
tion from  the  diseased  gland  and  would  pass  your  instrument 
through  it.  I  have  sometimes  imagined  that  this  method  of 
operating  contributed  to  open  the  cleft  or  valve-like  mouth  of 
the  tumid  prostate. 

I  am  next,  I  confess,  anxious  to  make  the  due  impression  on 
my  reader's  mind,  when  I  come  to  explain  a  prejudice  which  has 
indeed  almost  ceased  to  appear  in  this  odious  light,  from  being 
avowed  by  men  of  high  reputation  and  supported  by  facts.  It 
has  been  asserted,  that,  though  upon  introducing  the  catheter, 
blood  flows  from  the  urethra  in  a  full  stream,  "  No  harm  is 
done ;  such  haemorrhage  is  rather  useful,  and  facilitates  every 
future  attempt  to  pass  the  instrument."  I  will  freely  acknow- 
ledge that  often,  from  a  slight  injury  a  great  profusion  of  blood  , 
will  flow ;  this  is  an  inevitable  consequence  of  the  peculiar  struc- 
ture of  the  parts,  and  no  great  harm  ensues ;  but  that  such  a 
discharge  of  blood  is  entirely  harmless,  is  a  sign  of  dexterity, 
or  of  any  thing  but  awkwardness,  violence,  and  a  breach  of  the 
cellular  substance,  I  cannot  allow. 

*  In  this  cafe,  as  well  as  the  foregoing,  the  patient  will  be  in  general  relieved 
by  bleeding,  anodyne  injections,  &c.  For  even  where  ftrictures  exift,  fpafm  is 
frequently  the  immediate  caufe  of  the  retention  of  urine.    S. 


(     199     ) 


DISCOURSE  XIV, 


OF  THE  VARIOUS  CAUSES  OF  OBSTRUCTION 
OF  URINE;  STRICTURE,  STONE,  INJURY  OF 
THE  PARTS  FROM  BLOWS,  &c. 


SECTION    I. 


Of  Stricture. 

X  HE  stream  of  urine  small  and  tortuous,  even  in  the  sound 
state  of  the  parts,  impresses  us  naturally  with  an  erroneous 
conception  of  the  size  of  the  urinary  canal.  Mr.  Home,  having 
injected  it  with  wax,  was  surprised  to  find  the  roll  which  repre- 
sented the  urethra  so  large  ;  and  I  myself,  whtn  1  made  a 
drawing  of  the  urethra,  could  hardly  believe  my  draw- 
ing at  all  correct  or  faithful  ;  for  the  urethra  though  corru- 
gated in  the  living,  is,  when  expanded  in  the  dead  and  dis- 
sected parts,  full  half  an  inch  broad.  This  canal,  made 
for  dilatation,  is  full  of  rugae  ;  and  the  bigness  of  the  stones 
which  pass  along  the  canal,  and  the  size  of  the  catheter  which 
it  receives  with  case,  intimate  to  us  its  natural  dimensions  and 
peculiar  conformation,  which  is  such  as  to  enable  it  to  dilate 
into  a  large  sac,  wherever  the  passage  is  obstructed  by  a  stone 
or  stricture,  and  the  urethra  is  forced  by  the  propulsive  power 
of  the  bladder. 

It  is  to  no  peculiarity  of  organization,  that  I  would  ascribe 
the  disease  we  call  a  stricture  of  the  urethra  :  I  ascribe  it  nei- 
ther to  the  rugous  form  of  the  internal  membrane,  nor  to  the 
muscular  and  contractile  power  with  which  the  whole  canal  is 
supposed  to  be  endowed  ;  though  the  fact  of  an  occasional  or 
spasmodic  stricture,  ending  in  permanent  disease,  seems  to  ar- 
gue this  very  strongly.  As  the  tumour,  which  is  a  wart  on  the 
skin,  is  a  pile  when  growing  near  the  anus,  or  a  polypus  when 
in  the  passages  of  the  nose  or  uVoat  ;  so  that  vascular  action 
and  thickening  of  parts,  which  externally  would  form  a  tumour, 


200  Of  Stricture. 

forms  a  stricture  in  any  hollow  tube  ;  and  the  stricture  is  still 
the  same,  whether  it  form  in  the  throat,  rectum,  urethra,  or  pre- 
puce. Stricture  is  tumour,  and,  as  a  tumour  must  perpetually 
increase  while  the  circulation  survives  in  the  part,  unless  a  to- 
tal adhesion  of  the  canal,  by  obliterating  the  cavity,  put  an  end 
to  the  action.  "  When  in  a  small  degree,  (says  Mr.  Home) 
this  contraction  appears,  upon  examination  alter  death,  to  be 
simply  a  narrowing  of  the  canal  at  that  part ;  but,  when  the  con- 
traction is  increased,  it  becomes  a  ridge,  projecting  into  the  ca- 
nal:''    Page  21. 

Those  who  have  been  troubled  with  an  occasional  or  spas- 
modic stricture  of  the  urethra,  have  every  reason  to  fear  that 
it  will  become  permanent :  yet  I  have  often  observed  stricture 
to  be  merely  spasmodic,  and  I  think  I  have  found  it  often  a 
sort  of  febrile  disease.  The  stricture  I  speak  of  is  more  fre- 
quent in  winter,  arises  from  cold,  is  attended  with  fever,  and 
is  more  easily  cured  by  any  thing  than  the  bougie,  which  but 
aggravates  the  complaint.  This  febrile  stricture  I  have  fre- 
quently cured  in  men  of  the  most  chaste  and  exemplary  lives, 
free  from  the  slightest  pollution,  married,  and  of  intelligence 
much  above  any  kind  of  secrecy,  where  they  were  once  pleased 
to  give  their  confidence,  men  who  never  were  diseased.  The 
fit  of  obstruction  is  preceded  by  head-ach,  languor,  and  listless- 
ness,  while  the  obstruction  continues  :  and  the  accession  of  the 
hot  stage,  which  comes  on  in  the  evening,  and  especially  the 
paroxysm  of  perspiration,  which  comes  on  during  the  night,  is 
g  nerally  a  forerunner  of  relief.  I  have  seen  the  obstruction  so 
complete  that  not  one  drop  of  urine  has  passed,  though  accom- 
panied with  a  degree  of  desire  which  urged  the  patient  to  place 
himself  in  the  posture  every  quarter  of  an  hour,  and  with  such 
violent  straining  as  produced  a  partial  erection  of  the  penis, 
whence  always  the  obstruction  became  complete,  though  not  so 
before  :  the  bougie  being  at  the  same  time  resisted  at  a  single 
point  as  fairly  as  if  the  stricture  were  permanent  and  organic. 
I  have  gone  to  such  a  patient  at  midnight,  with  catheters  and 
bougies,  resolving  to  relieve  him  from  the  distention  of  the 
bladder  :  yet  feeling  a  degree  of  reluctance  at  using  harsher 
means,  I  have,  by  ordering  a  sharp  emetic,  followed  up  by  a 
strong  dose  of  laudanum  with  hot  wine  and  water  ;  by  rubbing 
the  perinaeum  very  hard  at  the  same  time  with  camphorated 
mercurial  ointment ;  and  by  fomenting  the  lower  part  of  the 
belly,  if  necessary,  with  a  hot  stimulant  fomentation,  or  wrap- 
ping the  parts  in  a  large  poultice,  been  saved  from  doing  any 
thing  painful,  and  have  been  rewarded  for  my  patience  and  pru- 
dence, by  seeing  the  urine  discharged  freely  next  day,  and  con- 
tinue to  flow  in  a  full  and  easy  stream. 


Of  Stricture.  201 

I  have,  after  a  scene  of  this  nature  was  over,  found  the 
bougie  pass  with  perfect  ease  into  the  bladder,  and  have  the 
pleasure  of  knowing  that  many  who  have  been  alarmed  with 
these  symptoms  have  continued  for  years  free  from  organic 
disease,  though  thus  affected  from  spasm. 

The  sudden  and  total  obstruction,  which  I  have  just  describ- 
ed, is  often  seen  in  the  conclusion,  but  rarely  in  the  commence- 
ment, of  proper  stricture,  which  usually  betrays  itself  by  little 
accidents,   and   symptoms  not  at  all  distressing.     The   patient, 
who  has  a  real  stricture,  whether  from  venereal  complaints,  from 
excess  committed    in  warm  climates,  or  from  any  accidental 
cause,  is   far  gone  in  this  malady  before  he  is  conscious  of  it. 
He   is  first  thoroughly  alarmed  by  a  sudden  interruption  of  his 
urine,  when,  having  remained  at  table  with  his  friends,  he  has  al- 
lowed the  bladder  to  fill  beyond  its  natural  and  easy  condition  ; 
for  that  straining  which  accompanies  over-fulness  of  the  bladder, 
causes  a  state  of  half  erection  of  the   penis,  the  cellular  sub- 
stance thus  filled  with  blood,  compresses  the  canal  of  the  ure- 
thra, and  aggravates  any  latent  stricture,  till  the  urine   is  actu- 
ally  interrupted.     The  patient,  the   more   he  strains,  feels  the 
difficulty  the  more  ;  he  but  increases  it  by  straining,  and  now 
observes,  in  a  particular  manner,  the  smallness  and  the  spiral 
form  of  the  stream   of  urine  :  from  this  unfortunate  hour  his 
situation   attracts   his  attention,  and   his  disease  increases;  he 
recollects  that  at  times,  especially  after  coition,  he  has  had  such 
a  degree  of  running  for  three  or  four  days  as  has  inclined  him 
to  believe  himself  infected  with   gonorrhoea  ;  he  has  felt  occa- 
sionally slight  pain  in  the  urethra,  accompanied  with  very  fre- 
quent desire  to  pass  urine,  which  he  is  in  the  custom  of  dis- 
charging every  three  or  four  hours.     He  now  remembers  that 
for  some  time  he  has  been  forced  to  rise,  according  to  the  quan- 
tity he  drinks  at  supper,  three  or  four  times  during  the  night ; 
and   all  this  he  would  willingly  ascribe  to  spasm,  because  or- 
ganic stricture  is  indeed  always  accompanied  with  spasm ;  the 
difficulty  of  making  urine,  far  from  being  permanent,  returns  in 
paroxysms,  is  aggravated  by  cold,  increases  in   winter,  and  in 
summer  almost  disappears,  is  easy  while  the  patient  is  in  a  warm 
chamber,  is  absent  almost  entirely  when  he  perspires,  returns 
upon  exposing  himself  to  the  air,  and  those  paroxysms,  which 
last  three  or  lour  days,  proceed  usually  from  changes  of  habit, 
so  slight,  that  he  can  hardly   mark   the  cause.     But  this  run- 
ning like  a  gleet,  returning,   upon  using  venery,  accompanied 
with  irritation,  but  never  arriving  at  the  virulence  of  a  clap  ;  this 
occasional  difficulty  of  passing  urine,  and  the  frequency  of  the  de- 
sire to  pass  it,  are  among  the  most  certain  signs  of  incipient  stric- 
ture, which   ends  at  last,  sometimes  in   the    course  of  a  few 

2   C 


202  Of  Stricture. 

months,  (though  often  it  is  delayed  for  years)  in  unequivocal 
disease. 

This  scene  of  suffering  once  begun,  is  renewed  from  time  to 
time.  The  running,  and  the  desire  to  pass  his  water,  increase 
every  time  he  attempts  coition,  and  he  is  threatened  with  abso- 
lute and  total  obstruction  even  time  he  drinks  hard,  or  rides  a 
hunting,  or  travels  post,  exposes  himself  to  cold,  is  seduced 
into  debaucheries,  or  any  way  interrupts  the  quiet  tenor  ol  his 
life  ;  and  when  stricture  is  thus  confirmed,  it  is  accompanied 
with  new  and  unequivocal  sensations,  for  along  with  urine  the 
semen  is  obstructed,  coition  is  attended,  in  the  moment  of  emis- 
sion, with  a  spasmodic  action  of  the  accelerator  muscle,  cre- 
ating a  sharp  and  thrilling  pain  ;  though  the  sense  of  emission 
is  complete,  the  point  o!  the  penis  continues  dry  ;  the  semen 
recedes  into  the  bladder,  and  sometimes  is  observed  to  flow  a- 
long  with  the  urine  :  in  this  state  of  things  barrenness  is  one 
consequence  of  the  obstruction,  though  it  be  in  such  a  degree 
only  as  retards,  without  entirely  preventing,  the  rapid  ejection 
of  the  semen. 

Betwixt  that  obstruction  in  which  the  urine  is  forced  off  drop 
by  drop,  with  violent  straining,  and  that  in  which  the  bladder  is 
entirely  obstructed,  the  limits  are  extremely  narrow,  the  slight- 
est imprudence,  the  being  unavoidably  exposed  to  cold  and 
moisture,  will  suddenly  bring  such  a  patient  (like  one  labouring 
under  hernia)  into  extreme  peril ;  for  after  the  obstruction  has 
passed  a  certain  point,  no  straining  will  force  off  one  drop  of 
urine  ;  nothing  but  the  introduction  of  the  catheter  can  give 
relief,  and  it  is  not  in  every  village  that  assistance  can  be  pro- 
cured. If  the  surgeon  arrives  but  a  little  too  late,  the  bladder 
is  distended  to  its  utmost  pitch,  and  far  beyond  its  natural  size, 
the  tossing  and  uneasiness  art  very  great,  the  abdomen  begins  to 
be  inflamed,  the  pulse  is  quick,  the  tongue  parched,  the  lips 
black,  the  eyes  inflamed,  the  visage  pale  and  ghastly  ;  and  the 
patient,  after  twenty-four  hours  of  insensibility,  or  of  low  and 
muttering  delirium,  expires.  Thus,  in  villages  and  parts  re- 
mote from  help,  many  valuable  lives  have  been  lost;  and  when 
in  this  doubtful  state,  not  apparently  ill,  yet  bordering  on  the 
greatest  dangers,  no  officer  can  go  to  sea,  no  soldier  can  go  in- 
to service,  no  country  gentleman  can  retire  to  his  estate,  with- 
out extreme  hazard. 

Without  most  culpable'imprudence  the  disease  is  rarely  fatal, 
but  the  patient,  by  the  natural  course  of  things,  falls,  if  neglect- 
ed, into  a  most  miserable  and  loithsome  condition  ;  for,  from 
the  moment  that  the  obstruction  is  nearly  complete,  the  portion 
of  the  urethra,  which  lies  behind  the  stricture,  is  exposed  to  the 
whole  force  of  the  bladder  and  abdominal  muscles,  it  is  soon 


Of  Stricture.  203 

affected,  as  an  artery  is  in  natural  aneurism,  (i.  e.)  it  is  first  di- 
lated, then  inflames,  then  bursts,  then  the  urine  spreading  (as 
yet  not  wideh)  among  the  cellular  substance,  causes  indurations 
of  a  singular  hardness,  as  if  they  were  rather  knots  of  callus, 
gathering  round  a  fractured  bone,  than  inflamed  cellular  sub- 
stance surrounding  a  breach  in  this  thin  and  delicate  tube. 
Such  thickening,  excited  by  the  urine,  forms  but  a  slight  and 
temporary  barrier  to  the  ruptured  part  ot  the  urethra  ;  the  knot 
extends  and  grows,  it  becomes  red  on  the  surface  and  softens, 
it  suppurates  with  little  pain,  and  bursts  slowly  ;  but  when  it 
bursts,  the  urine  issues  through  the  opening,  the  abscess  spreads 
in  various  directions  ;  the  surrounding  parts  are  all  affected  ;  the 
patient  often  loses,  from  mere  irritation,  the  power  of  retain- 
ing his  urine,  the  ulcers  and  fistulas  become  foul  and  sloughy, 
the  linens  and  the  bed  are  incessantly  moistened  with  urine. 
The  patient  is  exhausted  with  fits  of  incessant  vomiting,  and  is 
shaken  by  paroxysms  of  fever,  apparently  peculiar  to  this  dis- 
ease, such  as  make  his  teeth  chatter  and  the  bed  shake  under 
him  during  the  cold  stage,  and  when  the  sweating  comes  on, 
the  sheets  and  bed-clothes,  the  bed,  and  even  the  mattress,  are 
soaked  with  perspirations,  and  the  smell  of  his  room  resem- 
bles that  of  a  Russian  bath.  If  in  this  condition  he  be  neglect- 
ed but  a  few  weeks,  or  unskilfully  treated,  if  that  fever  is  com- 
bated with  bark  and  emetics,  which  ceases  only  when  proper 
surgical  incisions  are  performed,  if  the  obstruction  is  left  un- 
touched, and  the  sinuses  unopened,  and  the  matter  permitted 
to  work  its  way  deeper  among  the  cellular  substance  ot  the  pel- 
vis, the  patient  sinks  gradually  lower  and  lower,  loses  all  de- 
sire for  food,  has  a  cadaverous  and  jaundiced  aspect,  Jaints 
when  raised  in  bed,  and  at  last  dies. 

Stricture  is  a  tumour  or  growth,  and  the  striking  a  firm  bou- 
gie into  the  ring,  and  wedging  it  there,  can  do  nothing  but  ex- 
cite the  action,  by  which  the  stricture  is  produced.  I  have  seen 
the  patient  under  the  old  regimen,  endure  much  torture,  and 
with  wonderful  fortitude.  The  wedging  the  bougie  into  a 
stricture,  recalls  all  the  feeling  to  that  part,  and  excites  an  in- 
expressible desire  to  pass  the  water,  to  retain  the  bougie  half 
an  hour  at  first  using  it,  is  impossible  ;  the  irritation  does  not 
cease  when  the  bougie  is  withdrawn  ;  after  the  passages  are  in- 
flamed the  mucous  flux  is  increased,  the  desire  to  pass  urine 
bexomes  extremely  urgent,  if  the  urine  passes  more  easily  at 
first,  the  relief  is  but  momentary  ;  never  can  the  patient  feel 
relief  till  after  he  has  learnt  to  endure  the  bougie  for  hours,  and 
continued  to  wear  it  for  months.  To  live  thus  for  months  or 
years,  is  but  protracted  misery  ;  and  to  see  the  stream  ol  urine 
gradually  lessen  at  every  intermission  of  torture,  and  to  be  sen- 


204  Of  Stricture. 

sible  that  the  disease,  never  cured,  tends  incessantly  to  return, 
make  the  patient  desperate,  and  he  feels  that  life  is  not  worth 
holding  on  such  terms.  It  is  this  state  of  protracted  torture 
and  disappointment  that  affects  so  visibly,  the  physiognomy, 
temper,  and  general  health  of  a  patient  who  has  stricture  ;  it  is 
this  that  produces  the  chagrined  countenance,  sallow  com- 
plexion, and  wasted  habit;  and  oiten  it  happened,  while  bougies 
were  used,  that  false  routes  were  produced  by  the  irregular 
pressure  of  the  point  of  the  bougie,  cavities  were  formed  by 
the  sides  of  the  canal,  and  the  canal  itself  well-nigh  obliterated 
by  this  new  cause  of  compression  ;  the  bougie  passing  thus  in- 
to the  cellular  substance  by  the  side  of  the  stricture,  the  ure- 
thra behind  the  stricture,  dilated  under  the  force  of  the  bladder, 
and  the  parts  fell  into  a  complicated  state  of  disease. 

With  this  long  suffering  and  ill  success,  let  us  contrast  the 
effects  both  immediate  and  ultimate  of  the  caustic  bougie. 
When  the  caustic  is  pressed  against  the  ring  of  a  stricture,  none 
of  those  ill  consequences  predicted  by  theorists,  ever  are  pro- 
duced ;  there  comes  over  the  patient  a  confusion  and  a  sort  of 
alarm  arising  from  the  novelty  of  the  sensation,  which  makes 
the  most  vigorous  and  hardy  man  tremble  like  an  hysterical  girl, 
and  shiver  for  ten  minutes  with  the  pale  and  contracted  visage 
of  one  in  terror.  Yet  the  patient  is  not  in  a  state  of  suffering  ; 
he  talks  all  the  while  freely,  and  feels  neither  any  deep  sense  of 
burning,  or  any  other  description  of  pain.*  Nor  is  there  any 
thing  of  that  immediate  inflammation  and  swelling  which  it  was 
so  natural  for  the  theorist  to  predict,  which  it  was  supposed 
would  infallibly  close  the  canal,  and  entirely  suppress  the  flow 
of  urine,  at  least  for  a  time.  There  is  indeed  very  often,  a 
haemorrhagy,  but  it  is  of  that  kind  which  has  been  thought  so 
slightly  of,  when  it  flows  from  introducing  the  catheter  ;  and  in 
the  present  case  alone  is  such  haemorrhagy  desirable ;  for,  as  it  is 
a  sign  of  the  caustic  having  penetrated  to  the  cavernous  body  of 
the  urethra,  it  is  a  sign  of  success.  Neither  does  the  effect  of 
the  caustic  extend  along  the  canal,  nor  operate,  except  on  that 
point  against  which  it  is  pressed  ;  the  swelling  even  of  the 
burnt  part  is  not  perceptible  ;  the  mere  act  of  touching  the 
stricture  with  the  caustic,  instantly  gives  a  degree  of  relief ;  for 
the  caustic  kills  what  it  touches  ;  there  is  no  intermediate  state 
of  inflammation  ;  the  part  shrinks,  and  the  opening,   though 

•  Notwithstanding  what  Mr.  Bell  here  fays,  patients  fometimes  evince  by 
tbeir  actions  that  they  fuffer  the  moft  txcruciating  agony  upon  the  introduction 
of  the  cauftic,  as  I  have  often  feen;  and  wherever  the  common  bougie  would 
anfwer,  (and  that  it  frequently  will,  I  can  aver)  I  fliould  prefer  it.     S. 


Of  Stricture.  205 

affected  but  in  a  trivial  degree,  is  actually  and  instantly  enlar- 
ged; in  short,  the  name  only  of  caustic  is  alarming.* 

The  bulb  of  the  urethra  is  a  natural  dilatation  of  the  canal, 
fit  for  receiving  the  semen,  which  is  poured  into  it  during  coi- 
tion, and  ejected  from  it  by  the  smart  action  of  the  accelerator 
muscle,  in  the  moment  of  emission.  Immediately  behind  this 
dilatation  or  sac  of  the  bulb,  the  urethra,  where  it  enters  the 
bulb  is  naturally  narrow,  and  joins  the  bulb  with  something 
like  a  ring,  or  natural  stricture  ;  and  it  is  here,  at  this  point  na- 
turally straight,  that  the  stricture  is  formed  ;  a  second  stricture  is 
often  found  a  little  beyond  this  point,  about  half  an  inch  nearer 
the  neck  of  the  bladder  :  and  whether  there  be  one  or  more 
strictures,  they  He  so  far  down  in  the  urethra,  that  ohe,  unac- 
customed to  introduce  the  bougie,  would  believe  that  he  had 
passed  it  along  the  whole  canal,  and  that  it  had  entered  the 
bladder  ;  and  when  he  feels  resistance,  he  would  suppose  it  to 
arise  from  the  natural  straightness  of  the  prostate  gland  :  if  there 
be  other  strictures  than  those  near  the  neck  ot  the  bladder,  they 
are  usually  in  the  penis,  often  about  the  middle,  very  commonly 
in  that  part  of  it  from  which  the  scrotum  hangs. j" 

It  is  the  number  of  successive  strictures  that  makes  the  most 
formidable  resistance  to  the  passage  of  the  urine,  and  a  ptrson 
unacquainted  with  this  department  of  practice,  having  applied 
his  caustic  and  at  last  plumped  his  bougie  unprcmeditatedly 
and  suddenly  through  a  complete  stricture,  would  be  apt  to 
triumph,  but  the  urine  flows  not  a  whit  the  more  easily  ;  and 
upon  introducing  a  bougie  as  a  probe,  the  second  stricture  is 
distinctly  felt. 

There  is  no  other  evidence  of  the  existence  of  permanent 
stricture  but  the  bougie,  nor  is  it  even  a  very  absolute  test :  I 
have  found  the  bougie  stick  firm,  as  if  engaged  in  a  stricture, 
which,  after  the  spasm  which  stopped  it  had  subsided,  has 
passed  with  perfect  ease.  I  have  often  seen  the  bougie  intro- 
duced by  the  patient,  and  so  fixed,  either  by  its  point  hitching 
within  one  of  the  lacuna;,  or  by  some  other  accident,  that  no  de- 
gree of  force  could  have  driven  it  onwards,  whereas,  upon 
withdrawing  it  a  little,  and  passing  it  on  in  a  true  direction,  or 


*  For  a  very  ludicrous  denunciation  of  dangers  to  be  apprehended  from  cauftic, 
by  half  a  dozen  of  grave  and  learned  Doctors  and  1-roltfiors,  iee  in  Mr  Home's 
book  on  Strictures,  page  5. 

f  "  Strictures  occur  molt  commonly,"  fays  Mr.  Home,  "  juft  behind  the  bulb 
of  the  urethra,  the  diftance  from  the  external  orifice  being  fix  and  a  half  or  feven 
inches ;  the  fituation  next  in  order  ol  frequency,  is  about  four  and  a  hall  inches 
from  the  orifice  of  the  glans  ;  they  do  occur  at  three  and  a  hall  inches  and  fome- 
timesalmoft  clofe  to  the  external  orifice.''  Home  on  Stri&ures,  2d  Edit.  pp.  27, 
28.     S. 


206  Of  Stricture. 

withdrawing  it  altogether  out,  and  using  a  fresh  and  firm  one  a 
little  larger,  it  has  gone  on  easily  to  the  bladder. 

When  your  own  or  your  patient's  suspicions  of  stricture  have 
gone  so  far  that  you  meet  with  him  to  decide  the  question,  you 
first  make  him  pass  his  water  before  you,  that  you  may  remark 
the  size  and  form  of  the  stream :  you  next  take  a  bougie  of  a 
respectable  size,  by  no  means  a  small  one ;  and,  having  oiled 
and  bended  it  somewhat  in  the  form  of  a  catheter,  you  intro- 
duce it  before  it  softens;  and  always,  in  passing  the  bougie, 
whether  simple  or  caustic,  you  are  quick  and  dexterous  in  run- 
ning it  up  to  the  constricted  part,  before  it  begins  to  soften, 
which  it  does  very  suddenly,  when  affected  by  the  heat  of  the 
urethra.  You  proceed  thus  :  you  raise  the  point  of  the  penis 
with  the  left  hand,  you  then  introduce  the  bougie  with  the 
right,  and  run  it  on  suddenly,  till  having  passed  the  scrotum  and 
reached  the  perinaeuiri,  you  change  your  left  hand  from  the  pe- 
nis to  the  perinaeum,  you  press  in  the  points  of  the  fingers  of 
your  left  hand  behind  the  scrotum,  and  run  them  back  along 
the  perinaeum,  accompanying,  as  it  were,  the  progress  of  the 
bougie ;  and  while  you  push  the  bougie  smartly  on  with  the 
right  hand,  you  press  in  the  perinaeum  with  the  fingers  of  your 
left  hand,  directing  the  points  of  your  fingers  so  as  to  turn  the 
point  of  the  bougie  directly  upwards,  before  the  anus,  at  the 
place  where  you  expect  to  feel  the  stricture.  You  feel  the  re- 
sistance and  assure  yourself  of  the  stricture.  You  satisfy 
yourself  that  the  bougie,  in  place  of  going  onwards,  is  curling 
up  under  the  force  of  the  pressure,  you  then  withdraw  the  bou- 
gie and  find  it  curled  like  a  pig's  tail,  but  with  a  point  not  at  all 
ruffled,  because  it  was  never  admitted  within  the  ring  of  the 
stricture,  so  as  to  receive  any  impression  from  it.  Either  now 
or  at  some  future  occasion,  you  measure  the  stricture,  by  using 
a  bougie  small  enough  to  enter  into  it ;  you  take  a  small  pointed 
and  stiff  bougie,  give  it  the  bend,  introduce  it  after  the  same 
manner,  but  instead  of  stopping,  for  fear  of  giving  pain,  you 
press  it  on  and  wedge  it  firmly  into  the  stricture,  where,  if  it  be 
pressed  but  a  very  little,  it  takes  a  hold  and  is  withdrawn  again 
with  difficulty,  and  with  a  sort  of  feeling  as  if  the  urethra  were 
inverted  by  it.  Upon  being  altogether  withdrawn,  the  wax  is 
found  ruffltd  on  the  point  of  the  bougie,  a  sort  of  ring  marks  the 
part  embraced  by  the  stricture,  and  the  progress  which  the  coni- 
cal point  of  the  bougie  had  made  in  the  stricture,  denotes  the 
size  of  the  ring. 

The  application  of  the  caustic  really  and  effectually  to  the 
stricture  thus  discovered,  is  no  easy  matter.  The  most  dexte- 
rous apply  it  sometimes  twenty  or  thirty  times  without  success, 
while  it  happens  not  unfrequently,  that  the  armed  bougie  plumps 


Of  Stricture.  207 

through  the  stricture  at  the  third  or  fourth  experiment.  Those 
bougies  which  are  made  in  London,  are  certainly  the  best,  for 
they  have  a  long  caustic  securely  lodged,  and  sufficiently  expo- 
sed ;  yet  I  make  armed  bougies  perfectly  satisfactory  to  my- 
self, by  cutting  the  pencils  of  caustic  nicely,  introducing  the 
point  of  a  sharp  pen  knife  into  the  point  ot  the  bougie,  and  turn- 
ing it  vertically,  till  the  centre  rolls  of  cloth,  of  which  the  bou- 
gie is  composed,  are  scooped  out  and  the  outer  circle  only  left  ; 
then  the  caustic  being  lodged  in  the  hollow  and  the  edges  of  the 
cloth,  of  which  the  bougie  is  composed,  folded  over  it,  a  small 
round  knob  of  the  caustic  is  left  exposed,  and  the  bougie  which 
had  softened  under  the  modelling  of  the  fingers,  is  laid  by  to 
harden  ;  the  edges  of  the  plaster  having  then  taken  a  firm  hold 
upon  the  caustic. 

When  the  caustic  bougie  is  to  be  introduced,  I  like  to  pass  a 
common  bougie  before  it,  liberally  besmeared  with  oil,  not  to  as- 
certain the  place  of  the  contraction  so  much,  as  to  lubricate  the 
passage,  and  make  the  caustic  glide  quickly  to  the  destintd 
point.  Then  placing  the  patient,  and  bending  the  bougie  as  just 
directed,  you  (having  oiled  the  point  of  the  urethra,  and  spread 
its  lips,  that  the  caustic  may  not,  as  often  happens,  touch  the 
point)  glide  the  bougie  down  nimbly  and  quickly  down  the  ure- 
thra till  it  is  resisted  by  the  stricture  ;  )  ou  then  change  the  fingers 
of  your  left  hand  quickly  from  the  penis  to  the  perineum,  and 
there  by  pressing  them  in  succession,  you  direct  and  work  on 
the  bougie  with  the  left  hand,  and  prevent  it  bending,  while  you 
force  it  into  the  stricture  with  the  right ;  and  all  this  must  be 
smartly,  nimbly,  and  dexterously  done,  for  the  bougie  soon  sof- 
tens and  bends,  and  \ou  have  no  longer  any  power  over  it:  ha- 
ving struck  the  bougie  firm  into  the  stricture,  you  keep  it  pres- 
sed home  against  it  for  a  few  minutes :  the  patient  at  first  feels 
very  little  indeed,  only  the  slight  pain  of  pressure,  which,  howe- 
ver together  with  the  novelty  ot  the  sensation  and  the  alarm, 
makes  him  blanch  and  almost  faint,  or  at  least  be  seized  with  a 
cold  and  trembling  fit,  shaking  as  if  in  an  ague.  The  pain  is 
nothing  compared  with  the  patient's  imaginings  ;  though  the 
name  of  the  caustic  sounds  alarming,  the  sense  ot  burning  which 
it  occasions  is  very  slight,  the  bougie,  after  a  few  minutes,  is 
withdrawn,  and  the  slight  irritation  occasioned  by  it  subsides. 

There  sometimes  accompanies  the  application  of  the  caustic, 
a  slight  tinge  of  blood,  a  degree  of  grdor  urine,  an  increased 
desire  to  pass  the  urine,  but  indeed  the  pain  and  irritation  are  so 
slight,  that  the  patient  is  contented  and  'easy  in  his  mind,  and 
his  urine  flows  more  freelv  than  betore  ;  he  is  at  all  events 
freed  from  that  apprehension  which  he  could  not  but  feel  when 
he  thought  of  having  a  caustic  bougie  passed  into  the  yard.   But 


208  Of  Stricture. 

the  stream  of  urine  which  was  a  little  enlarged  by  the  fir9t  ap- 
plication, becomes  smaller  again,  the  caustic  is  again  applied,  and 
on  the  fourth  or  fifth,  or  perhaps  the  eighteenth  or  twentieth  ap- 
plication, sooner  or  later,  it  passes  through  the  stricture,  and  the 
urine, if  there  be  no  second  stricture,  flows  with  perfect  ease. 

The  young  surgeon,  in  the  course  of  his  practice,  will  observe 
and  be  perhaps  alarmed  with   several   unexpected   circumstan- 
ces.    First,  he  will  sometimes  be  alarmed   with  the  apprehen- 
sion of  the  caustic  having  dropped  from  the  end  of  the  bougie, 
and  it  often  does  actually  excoriate  a  great  length  of  the  canal, 
but  the  worst  consequences  produced  even  by  this  accident,  are 
an  unusual  degree  of  irritation  in  the  course  of  the  canal,  a  run- 
ning, as  in  a  smart  gonorrhoea,  of  thin    and    bloody    serum,    a 
heat  of  urine,  slight  pain  in  the  perinseum,  and  sometimes  slight 
pain  in  the  testicle.    I  have  seen  large  flakes  of  the  lining  mem- 
brane of  the  urethra  discharged*  along  with  the  bloody  serum  ; 
but  the  worst  of  these   symptoms  subside,  and   in  a   few  days 
the  caustic  can  be  applied  again.    Secondly  he  will  be  surprised 
to  find,  when  he  chooses  the  largest  caustic  bougie    in  order  to 
make   sure  of  the  effects  of  his  caustic,  that  it  has  actually  no 
effect,  for  though  a  large  bougie  exposes  a  greater  surface  of 
the  caustic,  that  surface  does  not  come  in  contact  with  the  stric- 
ture ;  a  smaller  bougie  is  more  fairly  admitted  into  the  ring  of  the 
stricture,  and  has,  according  to  my  observation,   a  much  happier 
effect.     Thirdly,  he  will  be  surprised  with  the  rude  and  unu- 
sual sensation  the  bougie  conveys  to   his   finger    when  passing 
through  the  stricture  ;  for  at  that  particular  application  in  which 
it  passes  through,  there   is  no  determined    interruption  !  but  in 
the  moment  when  the  bougie  approaches  the  neck  of  the    blad- 
der and  is  passing  through  the  cauterized  ring,  it  is  felt  to  grate 
along  as  if  it  were  passing  through  a  shot  hole  in  a  rough  deal 
board.     Fourthly,  he  will  sometimes  be  alarmed  even   by  the 
happiest  presages ;  for  often  there  comes  on   so  profuse  a  hse- 
morrhagy,  that,  instead  of  urine,  nothing  but  blood   seems  to 
run  from  the  urethra,  in  a  full  stream,  as  freely  as  from  a  vein 
in  the  arm,  hanging  in  coagula  from  the  point  of  the  yard.     Yet 
such  haemorrhagies  imply  nothing  but  success,  for  they   arise 
from  the  sloughs  having  destroyed  the  stricture,  and  penetrated 
into  the  cavernous  body  of  the  urethra  :  a  profuse  hsemorrhagy, 
while  it  is  actually  harmless,  is  a  prognostic  of  a  speedy  cure. 

The  horror  and  shivering  which  the  patient,  though  suffering 
neither  fear  nor  pain,  cannot  suppress;  a  shivering  so  violent  as 
to  make  the  teeth  chatter  audibly,,  is  no  sign,  as  far  as  lean 
distinguish,  either  of  safety  of  danger,  of  success  or  lailure  ;  but 

*  Probably  flakes  of  coagulable  lymph  thrown  out  by    the  inflamed    mem- 
brane.    S. 


Of  the  Causes  of  Fistula.  209 

if  any  thing,  it  intimates  the  successful  application  and  action 
of  the  caustic,  for  in  the  same  patient  I  do  not  find  the  same 
paleness  or  trembling  upon  introducing  the  common  bougie.  I 
have  sometimes  on  the  evening  after  appl\  ing  the  caustic,  found 
my  patient  vomiting  from  the  nervous  affection,  and  some- 
times I  have  seen  him,  after  a  long  fit  of  shivering,  slightly  de- 
lirious, without  any  perceptible  fever.  The  sickness  and  deli- 
rium, resemble  those  from  intoxication.  The  sickness  is  of  so 
unusual  a  kind,  that  the  patient  has  not  time  to  stretch  out  his 
hand  for  the  basin,  and  the  delirium  or  confusion  of  the  head, 
accompanied  like  that  of  drunkenness,  with  particular  stupor. 
Fifthly,  the  young  surgeon  will  be  often  surprised  to  find,  while 
he  is  despairing  of  success,  that  his  patient  informs  him  of  his 
cure,  of  having  passed  his  urine  freely  and  in  copious  streams, 
and  especially  he  will  be  surprised  when  informed,  that  the  flood 
of  urine  has  pushed  on  before  it  a  stone  of  considerable  size. 
But,  in  truth,  stones  are  often  formed  behind  a  stricture,  from 
small  particles  of  gravel  sticking  there  and  accumulating  ;  and 
when  the  stricture  is  destroyed,  the  stone  passes  and  drops  into 
the  water- pot  the  first  time  the  urine  is  freely  discharged.  The 
surgeon  and  patient  are  alarmed  at  the  first,  by  every  unusual 
symptom,  are  soon  reconciled  to  the  use  of  the  caustic,  then 
become  familiar,  and  are  at  last  doubtful  of  any  effects,  bad  or 
good,  from  this  application  ;  but  a  surgeon  experienced  in  the 
use  of  it  is  not  dismayed,  although  he  perceive  no  effect  after 
many  applications.  The  bougie  often  starts  unexpectedly 
through  the  stricture,  the  fifteenth  or  twentieth  time  it  is  ap- 
plied ;  it  has  been  applied  forty  times,  by  the  most  skilful,  with- 
out effect,  and  has  at  last  succeeded.  To  mention  thus  the  oc- 
casional circumstances  which  accompany  the  cure,  is  perhaps 
the  surest  way  of  preventing  alarm,  and  ensuring  success. 


SECTION    II. 

OfFistulce  in  the  Perinceum  and  Urethra. 

From  these  simple  obstructions  I  proceed  to  describe  more 
complicated  scenes  of  distress,  arising  not  solely  from  stricture, 
but  from  any  cause  obstructing  the  urinary  canal :  for  whether 
a  stone  sticks  in  the  urethra,  or  by  a  blow  on  the  perinaeum 
swelling  and  inflammation  are  produced,  whatever  cause  pre- 
vents the  urine  from  passing  freely  exposes  the  urethra  behind 
the  obstruction,  to  be  dilated,  inflamed,  ulcerated,  or  even  burst 
by  the  force  of  the  bladder. 

It  is  not  to  be  told  what  difficult  and  perplexing  forms  this 

2D 


210  Of  the  Causes  of  Fistula. 

complaint  assumes,  how  anxious,  careful  and  curious,  the  sur- 
geon's inquiries  must  be  before  he  can  understand  the  extent, 
form,  and  other  circumstances  of  any  particular  fistulae  ;  I  shall 
therefore  be  at  pains,  both  by  my  arrangements  and  descrip- 
tions, to  give  the  young  surgeon  clear  conceptions  of  this  dis- 
ease. 

There  are  three  general  cases  which  demand  especial  atten- 
tion : 

First,  The  obstruction  of  urine  proceeding  from  some  vio- 
lence to  the  perinaeum,  from  a  blow,  a  fall,  or  other  accident 
by  which,  though  the  skin  remains  entire,  the  urethra  itseli  is 
lacerated,  and  the  urine,  obstructed  in  its  natural  passage,  bursts, 
along  with  the  extravasated  blood,  into  the  cellular  substance 
of  the  scrotum  and  perineum,  and  makes  external  openings  by 
causing  a  gangrene  of  trie  parts. 

Secondly,  The  canal  obstructed  by  the  sudden  impaction  of 
a  stone  in  it.  The  case  ill  understood,  and  the  urethra  expos- 
ed to  the  force  of  the  bladder,  by  which  it  is  dilated  into  a  sac, 
in  which  the  original  stone  is  gradually  augmented  in  size, 
while  other  stones  are  often  generated. 

Thirdly,  The  fistula  arising  sometimes  from  stricture ;  some- 
times from  venereal  or  scrophulous  ulceration,  which,  in  its 
progress,  is  accompanied  with  a  succession  of  abscesses,  various 
openings  through  which  the  urine  is  discharged,  and  extensive 
indurations  of  the  surrounding  cellular  substance  ;  till  at  last, 
the  perineum  and  scrotum,  perforated  at  various  points,  and 
discharging  urine,  pus,  and  flatus  from  the  putrid  cellular 
substance,  resemble  in  lividness  and  hardness  the  intrgu- 
ments  covering  a  diseased  bone,  while  the  patient  is  wasted 
with  successive  paroxysms  of  fever  and  pain  ;  by  want  of  rest, 
and  by  the  uncleanliness  and  offensive  smell.  Let  these  slight 
definitions  serve  to  indicate  the  chief  subjects  of  the  following 
discourse. 

The  membrane  of  the  urethra  is  delicate  and  easily  ruptured, 
and  the  cellular  substance  surrounding  it  is  like  a  vein  full  of 
blood  continually  circulating  in  it.  The  urethra  itself,  or  the 
cellular  substance  of  the  urethra,  is  often  burst  by  a  blow  or  fall 
upon  the  perinseum,  as  in  trying  to  leap  across  forms  or  chairs, 
or  slipping  a  foot  in  crossing  a  stile  ;  or  by  masons,  miners,  or 
sailors,  falling  from  a  height  and  alighting  among  loose  stones, 
or  upon  projecting  beams,  or  upon  the  breech  of  a  gun,  or  the 
fluke  of  an  anchor.  The  urethra,  or  cellular  substance  of  the 
urethra,  bi  ing  burst  by  a  blow,  the  blood  either  flows  from  the 
penis,  or  is  extravasated  in  the  perinseum  according  to  the  de- 
gree oOinjury. 

When  the  lining  membrane  of  the  urethra  alone  is  burst  by 


Of  the  Causes  of  Fistula.  211 

the  fall,  the  blood  runs  from  the  penis  in  a  full  stream  to  the 
great  terror  of  the  patient,  who  apprehends  the  most  horrible 
consequences ;  but  it  is  like  that  fnemorrhagy  which  follows 
the  rude  introduction  ot  the  catheter,  harmless :  the  blood 
flows  indeed  as  freely  as  from  a  vein,  but  it  coagulates,  and  the 
haemorrhagy  stops  of  its  own  accord :  it  is  indeed  renewed  by 
the  passing  ot  the  urine,  the  clots  which  are  in  the  urethra  be- 
ing forced  off  in  long  strings,  or  bolted  out  in  small  knotty  co- 
aguia  ;  but  it  stops  again  :  and  though  I  have  often  seen  such 
hdemorrhagy  proceeding  from  a  venereal  ulcer  in  the  urethra 
bleed  thus  lor  three  days,  and  though  I  have  at  last  been  obliged 
to  lay  a  compress  upon  the  penis,  and  lay  it  down  upon  the  bt  lly 
with  a  bandage  to  stop  the  haemorrhagy,  I  never  yet  saw  the 
patient  injured  by  the  loss  of  blood. 

I  have  had  patients  run  into  my  room  with  their  pantaloons 
filled  with  blood,  but  I  have  seldom  been  obliged  to  vise  pres- 
sure, to  which  the  whole  canal  of  the  urethra,  and  especially 
the  bulb,  is  so  fairly  exposed,  that  no  harm  can  ever  happen. 
When  blood  flowing  along  with  the  urine  comes  thus  from  the  cells 
of  the  urethra  it  flows  in  a  stream ;  and  when  coagula  are  form- 
ed they  are  long,  slender,  and  stringv ;  but  when  the  blood 
flows,  as  I  have  seen  it,  from  the  kidney  into  the  bladder,  or 
from  the  ulcerated  surface  of  the  prostate  (a  part  which  is  sur- 
rounded with  a  plexus  of  veins)  the  elots  are  very  condensed, 
round,  and  firm  ;  they  obstruct  the  urethra  and  neck  of  the  blad- 
der so  that  the  force  required  for  their  expulsion  is  very  great ; 
the  patient,  every  time  he  passes  his  urine,  stalks  about  his  room 
in  all  the  agonies  that  those  feel  who  have  actually  the  stone ; 
and  when,  after  many  efforts,  the  clots  are  propelled  through  the 
urethra,  they  bolt  out  to  a  great  distance. 

When  the  blow  is  very  violent,  the  bulb  of  the  urethra  is 
completely  burst,  blood  flows  from  the  penis  in  great  profu- 
sion, and  a  tumour  is  observed  in  the  perineum  arising  from 
the  same  extravasation  of  blood.  The  extravasated  blood,  like 
that  ot  an  aneurism,  makes  a  rapid  progress  among  the  loose 
cellular  substance  of  the  scrotum,  which  swells  sometimes  to 
the  size  of  a  child's  head.  The  blood  is  pushed  forward  also 
under  the  skin  of  the  penis,  till  the  swelling  of  the  prepuce  en- 
tirely hides  the  glands ;  and  the  blackness  extends  upwards 
over  the  bellv  and  down  the  thighs.  A  surgeon  well  acquaint- 
ed with  the  structure  of  the  parts,  even  though  not  skilled  in 
this  department  of  practice,  will  easily  perceive  that  the  urethra 
is  burst,  and  will  no  sooner  see  biood  effused  and  an  extending 
ecchymosis,  which  is  comparatively  harmless,  than  he  will  ap- 
prehend, next  an  effusion  ol  urine  into  thv  cellular  substance, 
which  is  full  of  danger ;   and,  the  moment  he  sees  an  effusion 


212  Of  the  Causes  of  Fistula. 

of  urine,  he  will  make  no  delay,  but  perform  those  incisions 
which  are  necessary  to  save  the  parts,  especially  the  skin  of  the 
perineum  and  scrotum  from  destruction.  VVhen  the  patient 
feels  the  sense  of  passing  urine  so  distinctly  that  he  cannot  be 
persuaded  that  it  is  not  passing,  but  by  seeing  the  point  ol  the 
penis  dry ;  when  the  scrotum  and  perineum,  which  were  at  first 
swelled  and  livid,  become  puffed  up  suddenly ;  when  the  swell- 
ing, which  was  at  first  firm  and  resisting,  becomes  soit,  and 
gives  a  crepitating  feeling,  and  especially  when  no  urine  passes, 
and  yet  the  patient  feels  the  usual  relief,  the  surgeon  may  be 
assured  that  the  urine  is  passing  into  the  cellular  substance ; 
that  the  parts  will  soon  fall  into  gangrene  ;  that  the  testicles,  and 
perhaps  the  penis,  will,  by  the  sloughing  of  the  skin,  be  left 
naked  and  exposed,  and  the  skin  of  the  perinseum  partly  or  en- 
tirely destroyed.  These  are  most  dangerous  circumstances, 
and  the  fate  of  the  patient  depends  directly  and  plainly  on  the 
talents  and  discernment  of  his  surgeon  :  and  there  are  two 
modes  of  proceeding,  one  of  which  leads  to  safety,  and  con- 
verts a  dangerous  accident  into  a  very  simple  case  in  surgery; 
the  other,  of  which  there  are  unhappily  too  many  precedents, 
leads  to  destruction. 

If,  when  the  surgf.on  arrives,  he  is  not  aware  of  all  the  con- 
sequences of  the  accident :  if  he  do  not  reflect  more  upon  the 
effusion  of  urine  soon  to  take  place,  than  upon  the  present  diffi- 
culty of  introducing  the  catheter ;  if  he  calls  a  consultation  of 
surgeons  chiefly  to  assist  him  in  the  introducing  of  the  catheter, 
or  in  consulting  about  tapping  the  bladder :  if  one  or  two  days 
are  lost  in  vain  attempts  to  introduce  the  catheter,  and  in  the 
unmeaning  and  trivial  occupation  of  applying  fomentations,  em- 
brocations, and  poultices  to  the  parts ;  the  parts  fall  inevitably 
into  gangrene  ;  and  it  has  actually  happened  that,  while  a  grave 
consultation  has  been  deliberating  on  the  means  of  drawing  off 
the  urine,  it  has  been  escaping  into  the  cellular  substance  and 
causing  gangrene  ;  and  after  gangrene  has  actually  taken  place, 
they  have,  in  a  fit  of  despair,  and  to  accomplish  they  knew  not 
what,  tapped  the  bladder  from  the  rectum  ;  and  yet,  after  all 
this  destruction  by  surgery  and  disease  has  been  consummated, 
the  parts  have  healed  in  so  kindly  a  manner  as  to  prove  that 
nothing  was  required  but  a  few  superficial  incisions  to  keep  the 
patient  in  safety. 

The  stricture  of  the  parts  and  usual  consequences  then  of  this 
accident  being  considered,  the  surgeon  cannot  easily  mistake 
what  is  to  be  done. 

First,  no  doubt  he  is  to  introduce  the  catheter  ;  it  is  the  most 
obvious  and  easy  means  of  preventing  effusion  of  urine,  and 
restraining  the  extravasation  of  blood  :   and,  if  the  flexible  ca- 


Of  the  Causes  of  Fistula.  213 

theter  can  be  introduced  and  left  in  the  bladder,  it  will  ensuie 
an  easy  cure.  But  generally  the  surgeon  will  find  a  degree  of 
obstruction  at  the  ruptured  part,  which  he  dares  not  overcome, 
and  be  sensible  of  the  point  of  his  catheter  lodging  in  a  sort  of 
sac.  When  he  is  conscious  that  he  cannot  pass  the  catheter, 
he  will  not  think  of  perforating  the  bladder  ;  if  he  is  to  perforate 
at  all,  he  will  perforate  the  perinaeum,  where  already  the  urine 
begins  to  he  effused,  and  where  his  knife  will  uncover,  and  his 
medicines  reach,  the  ruptured  part  of  the  canal.  He  will  treat 
this  case  of  effusion  of  urine  into  the  scrotum  and  perinaeum 
according  to  the  analogy  of  air  effused  from  the  lungs  or  trachea; 
i.  e.  he  will  take  care  to  provide  an  exit  for  the  urine  which  is 
already  effused  ;  and  he  will  be  caretul  to  support  a  free  outlet 
for  that  which  may  continue  to  be  discharged  till  the  natural 
passage  lor  the  urine  be  restored  by  nature  or  art.  With  these 
views  he  will  make  small  incisions  proportioned  to  the  bulk  of 
the  tumour;  he  will  place  one  incision  in  particular  so  over  the 
ruptured  purt  ot  the  urethra  (which  he  can  mark  by  the  stop- 
ping of  the  catheter  there)  as  to  provide  in  future  free  egress 
for  the  urine.  Having  relieved  the  parts  thus,  he  will  expect 
the  swelling  to  subside  so  lar  as  to  allow  him  soon  to  pass  the 
flexible  catheter  along  the  canal  of  the  urethra.  In  the  mean- 
while all  is  safe,  and,  when  he  is  able  to  introduce  the  flexible 
catheter  into  the  bladder  and  leave  it  there,  the  breach  of  the 
urethra  heals  over  it,  or  will  indeed  heal  without  the  catheter, 
if  the  external  wound  be  not  tortuous,  nor  fistulous,  but  free 
and  open.  No  poultice  nor  fomentation  should  be  applied  to 
parts  in  this  condition :  they  must  be  moistened  from  time  to 
time  with  vinegar  and  spirits :  they  must  be  kept  dry  and  clean, 
and  wiped  at  every  time  they  are  soiled  with  urine  :  the  com- 
presses dipt  in  spirits  should  be  supported  with  gentle  pressure  : 
the  wounds,  especially  that  which  is  opposite  to  the  urethra, 
should  not  be  crammed  with  lint  or  other  dressings,  but  dressed 
lightly  with  gentle  escharotics,  as  red  precipitate  mixed  in  a 
small  proportion  with  any  ointment.  The  sloughing  parts  (if 
there  has  been  a  great  destruction  of  parts)  must  be  touched 
lightly  with  turpentine,  not  burnt  up  by  a  perpetual  application 
of  it ;  and  any  edges  that  become  particularly  callous,  may  be 
touched  with  lunar  caustic.  It  is  so  essential  to  prevent  ill  con- 
sequences, that  the  parts  endangered  by  the  effusion  of  urine  be 
freely  exposed,  that  I  am  earnest  in  recommending  the  practice 
to  my  reader  on  all  occasions  of  this  kind. 

Yet  these  are  not  cases  of  fistula  :  there  is  no  long  continued 
disease,  no  callosity,  no  irregular  passages  through  which  the 
urine  flows  with  difficulty  ;  but  direct  and  clean  incisions,  which 
should  easily  heal :  nor  do  I  account  those  sores  to  be  properly 


214  Of  the  Causes  of  Fistula:. 

fistulous  which  proceed  from  stones  arrested  in  their  passage 
along  the  urethra  :  yet,  when  a  stone  stops  in  the  urethra,  and 
the  urethra  is  dilated  behind  it  in  form  of  a  sac,  it  is  a  mere  di- 
latation of  the  lubricated  canal,  and  the  surface  of  the  sac,  when 
at  last  it  does  burst  or  is  opened,  is  very  little  dibposed  to  gra- 
nulate or  heal.  The  surgeon,  who  is  thoroughly  acquainted  with 
the  structure  of  the  parts,  has  this  unquestionable  advantage,  that, 
in  any  given  accident,  in  any  complicated  case,  when  some  par- 
ticular cause  is  producing  disorder  and  exciting  disease,  he  rea- 
sons correctly  on  its  consequences,  foresees  all  that  may  happen, 
and  anticipates  whatever  symptoms  it  is  possible  to  prevent :  in 
the  case,  for  example,  of  stone  either  dropping  down  from  the 
kidney,  or  formed  in  the  bladder,  and  driven  on  by  the  stream 
of  urine  along  the  urethra,  he  will  easily  anticipate  the  conse- 
quences, or  at  least  understand  them  when  they  do  present. 

A  stone,  while  within  the  urethra,  is  pushed  on  by  the  stream 
of  urine,  but  the  moment  it  is  delivered  from  the  urethra,  and 
lodges  in  the  prepuce,  the  urine  no  longer  urges  it  forwards  ; 
and  if  the  prepuce  be  narrow,  the  stone  remains  there,  and  es- 
pecially in  boys,  who  are  unconscious  of  the  cause  of  their  pain, 
and  do  not  seek  relief,  it  remains  till  it  acquires  an  extraordi- 
nary size.  When  a  small  stone  is  thus  lodged  under  a  narrow 
prepuce,  the  stream  of  urine  being  from  time  to  time  particu- 
larly strong,  the  stone  presents  itself  at  the  narrow  opening  of 
the  prepuce,  the  prepuce  then  sustains  the  whole  force  of  the 
bladder,  and  is  dilated,  and,  by  successive  dilatations  and  fits  of 
inflammation,  it  is  made  to  thicken,  and  grow  into  a  sac  of 
considerable  size.  In  a  little  boy  the  prepuce  has  been  thus  en- 
larged to  the  size  of  a  French  apple,  the  size  of  the  bag,  and 
the  narrowness  or  stricture  of  its  point,  increasing  in  equal  pro- 
portion, and  the  stone  moving  within  the  sac,  like  the  pea  in  a 
cat-call,  often  presenting  so  as  to  obstruct  the  urine,  and  pushed 
back  by  the  mother  with  a  pin  or  bodkin,  so  as  to  give  the  boy 
relief  by  emptying  the  prepuce.  The  stone  has  been  allowed, 
from  the  timidity  of  parents,  to  remain  for  years  till  it  has  in- 
creased from  the  size  of  a  pea  to  that  of  a  nut,  and  in  men  grown 
in  years,  a  succession  of  such  stones  have  been  formed  under 
the  prepuce,  one  being  generated  as  another  was  discharged. 
The  inconvenience  of  pushing  such  a  stone  back  to  make  way 
for  the  urine,  has  been  endured  for  years  rather  than  endure  the 
simple  operation  for  the  phimosis,  viz.  cutting  up  the  foreskin. 

Stones  passing  along  the  urethra  are  often  interrupted  by  that 
narrowness  of  the  canal,  which  is  observable  immediately  be- 
fore the  bulb  whence  they  are  fixed  in  the  perinseum  :  often 
again  they  are  interrupted  at  the  very  point  of  the  glans,  the 
orifice  being  encircled  by  a  sort  of  membranous  ring,  which 


Of  the  Causes  of  Fistula.  215 

girds  it  and  makes  it  narrower  than  any  lower  part  of  the  canal. 
The  canal  is,  in  all  its  length  betwixt  those  two  points,  so  equa- 
ble in  its  diameter,  so  lubricated,  and  so  dilatable,  and  the  blad- 
der is  so  powerful  in  its  contraction,  that  the  stone  seldom 
stops  at  any  intermediate  point,  or  never  longer  than  a  day  ;  du- 
ring which  time  the  urine  passes  in  such  quantities  by  the  side 
of  the  stone  as  to  relieve  the  bladder,  while  the  bladder  dilates 
the  urethra,  so  that  the  stone  makes  its  progress  slowly,  insen- 
sibly, in  respect  of  its  descent,  but  with  great  pain.  I  never 
knew  a  stone  stop  at  any  other  point  than  either  the  perinseum, 
or  the  very  opening  of  the  glands.  I  never  have  found  it  ne- 
cessary to  cut  the  urethra,  nor  even  to  use  those  means,  as 
blowing  into  the  urethra,  or  dilating  it  in  any  other  way,  which 
have  been  spoken  of  ever  since  the  days  ot  Prosper  Alpinus  : 
in  ninety-nine  of  a  hundred  cases,  stones  once  engaged  in  the 
urethra,  pass  along  without  the  help  of  art  ;  but  if  they  are  de- 
layed it  is  in  the  perinaeum,  and  it  is  necessary  here  to  tell  the 
consequences. 

When  a  stone  actually  stops  in  the  urethra,  it  is  usuallv  at 
the  turning  of  the  urethra,  under  the  pubis,  at  that  narrower 
part  where  stricture  usually  occurs.  On  the  first  da\  there  is 
a  total  obstruction,  with  intolerable  pain,  from  which  the  pa- 
tient has  no  relief;  on  the  second  day,  the  force  of  the  bladder 
overcomes,  in  some  degree,  the  resistance  of  the  urethra,  and 
urine  begins  to  pass  by  the  sides  of  the  stone.  But  while  the 
urethra  is  suffering  this  pressure,  it  is  in  some  degree  dilated  ; 
and  if  the  stone  be  immovably  fixed  in  the  urethra,  the  dila- 
tation increases  till  such  a  sac  is  formed  as  is  capable  of  receiv- 
ing the  stone.  Then  it  rolls  back  into  the  sac  and  lies  there, 
out  of  the  course  of  the  urine,  which  passes  at  times,  freelv,  but 
at  times  is  interrupted,  the  stone  being,  by  the  contraction  of 
the  parts,  placed  opposite  to  the  urethra  :  and  thus  it  happens 
that  the  urethra  is  exposed,  from  time  to  time,  to  the  force  of 
the  bladder,  the  preternatural  sac  is  dilated  more  and  more,  and 
being  enlarged  much  beyond  the  size  of  the  original  stone,  is 
capable  of  containing  a  small  quantity  of  urine.  This  lateral 
sac  of  the  urethra  resembles  a  second  bladder,  and  other  stones 
are  formed  in  it:  now  the  parts  are  thickened,  the  bulk  is  very 
perceptible  in  the  perinseum  :  the  patient  sits  uneasily,  and  sel- 
dom passes  urine  without  interruption  and  pain  :  the  swelling 
either  is  in  the  back  part  of  the  scrotum  originally,  or  extends 
that  way.  The  patient,  from  long  habit  of  observing  his  situ- 
ation, can  recollect  that  often  while  the  urine  flows  in  a  full 
stream,  he  is  sensible  of  some  going  into  the  tumour  ;  and  after 
having  passed  his  urine,  he  can,  by  squeezing  the  swelkd  part 
of  the  scrotum   or  perineum,   press  out  a  small   quantity  of 


216  Of  the  Causes  of  Fistula. 

urine  extremely  fetid,  from  being  retained  in  the  sac  :  often, 
while  the  urine  is  flowing  in  a  full  stream,  he  finds  it  slop  sud- 
denly, from  the  presenting  of  one  or  other  of  the  little  stones  in 
the  proper  course  of  the  canal ;  and  that  there  are  such  stones, 
he  can  feel  distinctly,  for  as  the  stones  are  formed  in  the  sac, 
and  not  the  sac  moulded  upon  the  stones,  the  sac  is  large 
enough  to  let  them  rattle  so  against  each  other,  that  the  patient 
feels  them  within  the  tumour,  like  those  in  the  crop  of  a  bird. 

When  such  a  sac  is  opened  by  an  incision,  stones  are  found 
in  some  cases  to  the  number  of  sixty  or  eighty,  and  the  fistula 
is  nearly,  though  seldom  entirely,  cured  :  why  such  a  sac  is  not 
easily  cured  is  obvious,  for  the  formation  of  so  many  stones 
implies  a  long  continued  disease  and  callosity  of  the  parts  ;  the 
sac  is  generated  by  pressure,  distention,  and  successive  inflam- 
mations ;  there  is  a  remarkable  thickening  and  massing  together 
of  the  parts,  and  wh^n  the  tumour  is  opened  the  surgeon  feels, 
by  introducing  his  fing-r,  that  the  sac  is  so  smooth,  so  lubricat- 
ed, and  so  perfectly  analogous  with  the  inner  membrane  of  the 
urethra,  that  it  is  probably  a  simple  amurism-like  dilatation  of 
that  canal,  supported  by  a  thickening  of  the  cellular  substance  ; 
and  the  sac  formed  out  of  such  a  lubricous  membrane  is  not 
likely  to  inflame  and  heal. 

Perhaps  it  may  not  be  irrelevant  to  mention  here,  among 
the  diseases  ot  the  urethra,  an  accident  which  is  shockingly  fre- 
quent :  little  boys  who  in  their  dreams  wet  the  bed,  have  often, 
to  avoid  the  shame  and  the  punishment  of  such  a  fault,  tied 
tapes  about  the  penis,  and,  unable  to  undo  the  knot  in  the  morn- 
ing, have  concealed  their  situation  ;  and  I  have  known  parents 
so  fool-hardy  as  to  do  this,  and  have  seen  the  penis  cut  half 
across.  It  is  always  the  lower  side  of  the  penis,  or  that  on 
which  the  urethra  lies,  which  suffers  ;  and  the  only  remark  which 
I  have  to  suggest  is  this,  that  I  have  never  seen  any  good  done 
by  attempts  to  re-unite  the  parts  at  the  time  of  the  injury. 
That  the  applications  of  canthandes,  red  precipitate,  and  other 
irritating  applications,  in  place  of  assisting  the  re-union,  or  pro- 
curing granulation,  have  invariably  widened  the  breach.  I  ad- 
vise that  the  parts  be  suffered  to  heal ;  that  if  any  thing  be  in- 
troduced into  the  urethra,  it  be  only  a  leaden  probe  ;  and  that 
all  attempts  at  healing  the  breach,  be  deferred  till  the  parts  are 
skinned  over,  the  inflammation  entirely  gone,  the  orifice  cal- 
lous ;  and  then  by  paring  and  scarifying  the  edges,  retracting  the 
skin  of  the  penis,  securing  it  by  adhesive  plasters,  and  intro- 
ducing a  flexible  catheter,  it  may  be  readily  cured. 

These  are  accidents  comparatively  rare  ;  to  omit  the  mention 
of  them  would  indeed  be  wrong,  but  to  represent  them  as  fre- 
quent causes  of  fistulae,  would  be  to  deceive  my  reader:  let  ua 
turn  then  to  matters  of  daily  practice. 


Of  the  Causes  of  Fistula.  2 1 7 

That  inflamed,  indurated,  and  confused  state  of  the  parts, 
where  the  urine  having  ceased  to  flow  through  the  natural  canal, 
has  burst  through  the  perinaeum  in  various  irregular  openings, 
is  the  work  of  time,  and  proceeds  Irom  the  slow  operation  of 
some  continued  resistance  to  the  passage  of  the  urine :  stricture, 
and  venereal  disorders  of  the  urethra,  are  the  only  causes  which 
we  recognize  in  common  practice.  If  the  interruption  of  a 
stone  passing  along  the  urethra,  or  a  blow  bursting  the  canal, 
produce  a  fistula,  it  is  to  be  regarded  rather  as  an  accident,  and 
indeed  the  disease  is  more  easily  cured.  Strictures  are,  in 
ninety-nine  of  a  hundred  cases,  the  causes  of  fistulac  ;  for  irrita- 
tion and  frequent  desire  to  pass  urine  are  inseparable  from  a 
stricture,  which  is  continually  felt  as  a  foreign  body  :  the  fre- 
quent contractions  of  the  bladder  lessen  its  dimensions,  thicken 
its  coats,  and  increase  its  mascular  power ;  and  thus,  while  the 
bladder  is  acquiring  daily  increase  of  power,  and  its  contractions 
are  becoming  every  hour  more  frequent,  the  urethra  is  no  longer 
able  to  bear  the  pressure.  I  do  not  mean  to  say  that  the  ure- 
thra is  burst,  as  where  a  stone  impacted  in  the  urethra  totally 
shuts  the  canal,  but  it  is  dilated  by  the  continual  force  of  the 
bladder,  it  inflames,  the  surrounding  parts  are  soon  affected, 
and  thence  begins  the  disease  of  the  perinaeum. 

The  penis,  and  all  the  surrounding  cellular  substance,  are  so 
dull  and  obtuse  in  their  sensations,  that  though  the  former  is 
the  seat  of  a  peculiar  kind  ot  sensibility,  its  diseases  make  great 
progress  with  little  pain,  and  though  strictures  in  the  urtthra, 
and  abscesses  of  the  perina-um,  are  diseases  of  no  slight  impor- 
tance, yet  the  fact  is,  that  they  steal  upon  the  patient  by  such 
slow  and  insensible  degrees,  that  he  is  hardly  aware  either  that 
he  is  labouring  under  the  one  disease,  or  in  danger  of  the  other, 
before  he  falls  into  the  most  calamitous  circumstances. 

When  a  fistula  first  threatened  in  the  perin.eum,  you  may 
feel  the  callosity  firm,  knotty,  and  perfectly  moveable,  and  you 
can  move  the  urethra  sideways,  with  the  finger  and  thumb,  as 
if  the  bulb  were  injected  with  wax  ;  the  pressure  of  your  thumb 
squeezes  out  matter,  which  passes  into  the  canal  of  the  urethra, 
and  issues  from  the  penis  ;  and  such  a  tumour  I  have  seen  for 
many  alternate  days,  almost  vanish,  then  return  again,  and  at 
last  disappear  ;  whence  I  am  inclined  to  conclude,  that  such  a 
small  abscess  or  blind  fistula,  opening  not  outwardlv,  but  only 
into  the  urethra,  varies  in  size  according  to  thequantitv  of  mat- 
ter contained  in  it,  and  sometimes  is  cured  and  obliterated. 

From  the  time  that  urine  begins  to  issue  through  openings  in 
the  perinoeum,  the  disorder  becomes  every  moment  more  com- 
plicated, and  the  condition  of  the  patient  more  loathsome. 
When  the  urethra  is   obstructed  anew,  and  the  perineum  in- 

2  E 


218  Of  the  Causes  of  Fistula:. 

flames,  when  either  the  old  fistula?  are  about  to  burst  out,  or 
new  ones  are  iormmg,  the  patnnt  has  distinct  rigours  and  fever, 
and  clouds  do  not  more  certainl)  portend  a  storm,  than  rigour 
and  a  feverish  paroxysm,  the  generation  ol  some  new  fistula. 
It  is  not  a  shght  rigour  that  the  patient  is  assailed  with,  but  a 
cold  tit  like  th;tt  of  a  quartan  :  the  patient  leels  a  sickishness, 
languor,  and  giddiness  ;  his  lace  grows  pale,  and  the  circle 
round  his  eyes  livid  ;  and  when  the  fit  comes  on,  the  bed  shakes 
under  him,  and  his  teeth  chatter  audibly.  He  vomits  a  pro- 
fusion of  bile  ;  his  urine  is  sparing  and  high  coloured  ;  his  tem- 
ples throb,  and  the  hot  stage  which  succeeds  is  very  violent,  and 
is  followed  by  a  sweating  stage,  very  long  and  exhausting.  He 
is  bathed  in  sweat,  shirt  alter  shirt  is  changed,  and  is  actually 
wrung  out  before  it  is  thrown  into  the  closet.  The  bed-clothes 
are  thoroughly  soaked.  The  fetor  of  the  urine  passing  through 
the  fistulous  sores  and  wetting  the  linens,  and  the  extreme  fre- 
quency of  passing  water,  and  the  imperfect  manner  in  which  it 
passes,  the  patient  having  hardly  am  degree  of  retention,  make 
his  condition  most  miserable.  His  frequent  rising  to  take  the 
water-pot  during  the  night,  while  under  this  sweating-stage, 
gives  him  cold  and  aggravates  every  symptom.  The  patient, 
after  each  paroxysm,  looks  wan  and  meagre  ;  he  could  not,  in 
the  space  of  several  weeks,  entirely  recover  Irom  the  shock,  but 
weeks  are  not  allowed  him,  for  one  paroxysm  succeeds  another 
at  intervals  of  but  a  few  days,  bilious  vomiting  or  diarrhoea  of- 
ten occupies  the  intermediate  time,  and  the  surgeon,  with  all 
his  care  to  preserve  his  patient  from  fever,  is  hardly  able  to  find 
two  days  free  from  fever,  during  which  he  may  perform  his 
operations.  This  is  an  intermitting  fever  so  purely  sympto- 
matic, that  bark  or  wine,  or  antimonial  medicines,  are  of  little 
use  ;  thr  patient  very  generally  cannot  use  laudanum,  which 
only  increases  his  sickness ;  nothing  can  give  relief  but  destroy- 
ing the  stricture  and  opening  the  fistula;. 

The  catheter,  if  it  can  be  passed  or  retained  at  such  a  time, 
is  of  use,  by  preventing  the  impression  of  the  urine  upon  the 
parts  ;  and  extreme  cleanliness,  air,  and  exercise  in  a  carriage, 
and  the  warm  bath,  with  opiate  clysters,  palliate  the  distress 
till  a  fit  time  comes  for  attempting  the  cure. 

When  a  patient  commits  himself  to  your  care,  look  well  to 
his  condition,  reflect  maturely  on  every  circumstance  of  his  case, 
and  weigh  all  the  probabilities  before  you  promise,  or  seem  to 
promise,  a  cure  ;  although  he  has  been  long  labouring  under 
disease,  and  the  parts  are  in  grrat  disorder,  though  the  peri- 
neum be  perforated  with  irregular  openings,  and  abscesses  ex- 
tend Irom  the  urethra  to  the  scrotum  and  hip.  you  will  not  de- 
spair ;  because,  these  points  are  accessible.     But  when  the  eel- 


Of  the  Cure  of  Fistula,  219 

lular  substance  of  the  pelvis  is  deeply  affected,  when  flatus 
bursts  through  the  several  openings,  demonstrating  that  they  pe- 
netrate to  the  rectum,  though  you  will  never  abandon  the  per- 
son who  puts  his  confidence  in  you,  you  will  be  cautious  how 
you  express  your  hopes  of  saving  him,  to  his  friends. 

This  is  so  entirely  a  surgical  disease,  and  the  parts  are  so 
irregularly  affected,  that  natural  ingenuity  and  a  spirit  of  enter- 
prise are  ot  infinite  use,  and  a  nice  and  careful  hand  in  adapt- 
ing instruments  to  the  condition  of  the  parts,  and  laying  dress- 
ings so  as  to  keep  the  sores  dry  and  clean,  sometimes  periorm 
wonders.  The  surgeon  sits  down  to  reflect  deliberately  on  the 
causes  of  the  fistula;,  and  of  their  various  directions  and  com- 
munications, he  passes  first  the  catheter  or  bougie  into  the  u- 
rethra,  to  feel  lor  the  obstruction,  he  probes  each  fistulous  open- 
ing, to  discover  its  depth  and  direction,  and  its  communication 
with  other  openings,  and  to  observe  whether  the  probe,  when 
passed  through  the  fistulous  openings,  and  the  catheter  where  it 
is  stopped  in  the  urethra,  can  be  made  to  meet. 

He  examines  carefully  into  all  the  circumstances  of  his  pa- 
tient's case,  that  he  may  know  in  what  succession  the  several 
openings  burst  out,  and  in  what  degree  the  parts  have  suffered. 
He  then  tries  to  get  the  staff,  if  possible,  into  the  bladder,  in- 
troducing his  finger  at  the  same  time  into  the  anus,  that  he  may 
be  assured  whether  (here  is  any  disease  within  the  pelvis,  and 
beyond  the  reach  ot  his  knife.  On  the  clearness  of  his  cone  p- 
tions  and  reasoning,  does  the  fate  of  his  patient  entirely  depend  ; 
the  stricture  is  to  be  relieved,  the  fistula;  laid  open,  the  canal 
made  direct  and  clear,  and  the  incisions  healed  by  cscharotic 
applications:  and,  while  no  diseased  partis  to  be  span  d«  .no 
part,  either  of  the  urinarv  canal,  or  surrounding  integuments,  is 
to  be  wantonly  destroyed.  In  short,  care  and  cleanliness,  in- 
genuity and  industry,  a  perfect  knowledg-  ol  the  anatomy  of 
the  parts,  anil  a  mechanical  genius  for  contriving  various  means 
of  restoring  the  passage  of  the  urine,  and  healing  the  openings, 
are  of  inestimable  value  ;  they  are  talents  which  may  be  improv- 
ed and  cultivated,  and  will  eventually  save  the  lives  of  patients, 
who,  if  laid  in  a  foul  bed,  and  macerated  in  relaxing  poultices, 
would  die. 

Fortunately  there  is  no  doubt  nor  delicacy  concerning  these 
operations  on  the  perinasum,  which  seem  so  cruel,  and  which 
are  indeed  so  often  unsuccessful ;  the  natural  force  of  the  urine 
never  could  overcome  a  stricture  in  the  urethra,  and  the  peri- 
naeum  being  perforated,  even  that  ineffectual  force  is  taken  off, 
the  parts  are  running  every  moment  into  greater  disorder  ;  the 
most  vigorous  health  (and  that  is  not  to  be  expected)  can  never 
cure  those  sores,  while  the  obstruction  in  the  urethra  remains  ; 


220  Of  the  Cure  of  Fistula. 

the  suppurations  are  continually  spreading,  and  the  fever  in- 
creasing, so  that  something  must  be  done,  and  since  that  part 
of  the  urethra  which  lies  betwixt  the  stricture  and  the  point  of 
the  penis  is  now  of  no  use,  we  may  proceed  to  remove  the  stric- 
ture, and  since  the  urine  has  a  free  issue  by  the  perinaeum,  we 
are  not  interrupted  in  our  work. 

These  general  theories  of  the  disease  and  of  its  cure,  are  of 
use  to  give  the  surgeon  clear  conception  of  the  difficulties  he  has 
to  encounter  ;  but  that  he  may  learn  how  to  encounter  them,  I 
shall  proceed  to  lay  down  rules  lor  his  conduct  in  somewhat  of 
an  aphoristical  form. 

1st,  It  is  not  here  as  in  the  case  formerly  described,  (viz.  a 
sudden  bursting  of  the  urethra,)  the  first  duty  of  the  surgeon  to 
make  free  openings  in  the  perinaeum  ;  for  the  walls  of  a  fistula 
are  so  condensed  by  inflammation,  that  the  urine  is  not  injected 
into  the  cellular  substance,  but  flows  through  one  or  many 
openings,  whose  walls  are  firm  and  tube-like,  as  the  name 
fistula  implies.  The  first  care  then  of  the  surgeon,  in  every 
case  of  fistula,  whether  old  or  recent,  is  to  clear  the  canal,  and 
that  is  best  done  by  passing  a  caustic  bougie  down  the  urethra, 
If  there  be  plainly  a  stricture  in  the  urethra,  if  the  bulb  or 
lower  parts  are  just  beginning  to  give  way,  and  the  perinseum 
to  inflame,  let  the  caustic  bougie  be  applied  immediately  ;  or 
let  the'  common  bougie  be  forced  into  the  stricture,  to  procure 
a  momentary  relief,  by  freeing  the  passage  and  relieving  the 
perinaeum  from  its  immediate  pressure  ;  while  leeches  and 
saturnine  solutions  are  applied  to  the  perinaeum,  and  the  part 
supported  with  gentle  pressure.  Sometimes  in  proportion  as 
the  passage  is  cleared  by  the  caustic,  the  pain  and  swelling  of 
the  perinaeum  subside,  and  the  patient  is  saved  from  a  breach  in 
the  urethra. 

2d.  When  the  disease  has  proceeded  a  point  farther,  and 
there  is  not  only  an  inflammation  in  the  perinaeum, and  a  threat- 
ening of  danger,  but  an  actual  abscess  ;  the  surgeon  should 
make  no  delay,  but  open  it :  there  is  indeed  no  danger  of  the 
urine  being  diffused  widely  under  the  skin,  but  there  is  danger 
of  the  abscess  extending  itself,  of  more  cellular  substance  being 
destroyed  by  suppuration,  and  of  the  urine  being  admitted  into 
a  larger  sac ;  in  short,  the  abscess  in  perinaeo  will  always  be 
more  or  less  extensive,  in  proportion  as  it  is  more  or  less  pru- 
dently managed  ;  and  it  is  a  point  of  prudence  to  open  it  early. 
If  it  could  be  prevented  from  suppurating,  that  would  be  a 
great  point ;  but,  when  it  has  already  suppurated,  and  points  to 
a  head,  when  you  distinctly  feel  the  matter,  and  suspect,  from 
circumstances,  that  the  urine  has  access  to  the  abscess,  you  open 
it  without  loss  of  time,  with  the  point  of  a  lancet  ;  and  at  the 
same  time,  take  every  measure  for  freeing  the  natural  passage. 


Of  the  Cure  of  Fistula:.  221 

3dly,  In  cases  of  irregular  and  complicated  fistulas  which 
have  continued  long,  when  little  urine  passes  by  dv  urethra,  and 
much  through  fistulous  openings,  become  callous  by  time ; 
where  there  is  no  threatened  disease  whiih  may  be  prevented 
by  timely  incisons ;  where  either  the  surgeon  feels  plainly  one 
long  and  formidable  stricture,  or  suspects  various  openings  in 
distinct  parts  ot  the  canal,  he  will  first  give  his  whole  attention 
to  the  clearing  of  the  natural  passage,  that  he  may  afterwards 
deal  more  successfully  with  the  fistuiae. 

His  means  of  overcoming  such  strictures,  must  be  adapted 
to   the  circumstances  of  each.       It  he  has  reason  to  believe 
that  there  is  but  one  small  and  solitary  stricture,  he  will  per- 
haps hope  to  give  a  temporary  relief,  by  forcing  the  point  of  a 
bougie   into  it,  and  thus,  lor  a  moment,  taking  off  the  force 
from  the  perinaeum,  he  may  gain  time  for  the  use  of  the  caustic, 
and   be  able  in  a  more  deliberate  way,  to  destroy  the  stricture 
altogether,  and  restore  the  free  stream  of  urine.     It,  from  the 
history  of  the  complaints,  and  a  distinct  account  of  what  has 
been  done   by   former  surgeons,  if  trom  the  entire  obstruction 
ot    the   urine,    trom   the   extensive  fistula;  and  long  continued 
disease  in  the  perinaeum,  he  has  reason  to  believe  that  the  stric- 
ture is  verv  complete  ;  but  especially  it  upon  feeling  the  urethra, 
he  is  sensible  that  the  obstruction  arises,  not  trom  a  single 
stricture,  hard  and  round  like  a  pea,  at  one  point  of  the  urethra, 
but  from  several  contiguous  strictures  occup\ing  a  considerable 
length  of  the  urethra  ;  it,  to  speak  more   accurately,   he  feels 
with  the  finger  and  thumb,  a  space   of  the  urethra,  nearly  half 
an  inch  in  length,  small  and  hard,  like  a  big  thread,  at  which 
the  bougie  or  catheter  stops,  he  has  reason  to  tlar,  that  not  a 
hundred  applications  of  caustic  would  destroy  such  a  stricture, 
and  is  sensible  that  he  must  have  recourse  to  rougher  methods. 
He  introduces  the  stalk   of  a  silver  catheter,  the  bend  being  cut 
smoothly  off,  and  using  it  as  a  canula,  he  plants  the  point  of  it 
upon  the  stricture,  and  passing  down  a  trocar  or  piercer,  either 
squared  or  lancet-pointed,  and    grasping  the  urethra  firm  in  his 
lett  hand,   and  holding  the    piercer  firmly   with   his    right,  he 
bores  it  along,  (a    thing   which   cannot  be  done  without  much 
force  and  exquisite   pain   to  the  patient)  and  makes  his  way 
through  tne  stricture,  indifferent  whether  it  passes  through  the 
body  of  the  stricture  or  by  the  side  of  it,  if  only  it  meet  the 
open  part  of  the  urethra.       This  operation  I  hold  to  be  chiefly 
practicable  in  strictures  manifestly  of  considerable   length,  and 
occupying  the  middle  parts  of  the  urethra,  especially  that  which 
lies  within  the  scrotum ;  and  I  have  found  the  operation  greatly 
facilitated,  by  feeling  very  carefully  from  the  point  where  the 
catheter  stops,  so   as  to   ascertain  the   extent  of  the  stricture. 


222  Of  the  Cure  of  Fistula. 

making  the  patient  in  the  meanwhile  press  his  urine,  so  that  I 
would  feel  the  urethra  dilated  into  a  sort  of  sac,  behind  the 
stricture.  This  sound  and  dilated  part  of  the  urethra  is  that 
which  is  to  be  aimed  at  with  the  trocar:  I  have  found  it  neces- 
sary to  hold  the  urethra  and  penis  particularly  firm,  for  it  re- 
quires great  force  to  drive  the  piercer  on :  and  in  this  operation 
of  working  the  urethra  along  the  piercer,  as  you  would  put  the 
bait  on  a  fishing-hook,  I  have,  I  confess,  found  the  greatest 
difficulty  in  hitting  precisely  the  free  and  dilated  part  of  the 
urctnra  behind  the  obstruction.  The  lancet-pointed  trocar,  is, 
I  am  certain,  from  experience,  preferable  to  the  round  or  square 
pomtcd  trocar,  and  I  think  it  necessary  to  mention,  that  gene- 
rally and  almost  necessarily,  the  trocar  must  enter  the  side  of 
the  sound  part  of  the  urethra,  whence  there  will  be  a  degree 
of  crookedness  in  the  new  canal ;  and  if  there  be  any  collateral 
abscess  to  distort  the  urethra,  the  irregularity  will  be  verv  great, 
and  the  catheter  will  pass  this  point  with  a  degree  of  difficulty, 
and  not  without  som-  address  on  the  part  of  the  surgeon,  who 
must  learn,  bv  practice,  towards  which  side  the  obliquity  lies. 
To  prevtnt  or  lessen  this,  to  preserve  as  far  as  possible,  a  di- 
rect channel,  a  large  leaden  probe  as  big  as  the  catheter  should 
be  worn  during  the  cure,  and  the  caustic  occasionally  used : 
this  operation  of  perforating  is,  I  acknowledge,  difficult  and 
delicate,  but  we  speak  now  of  cases  where  bougies  are  merely  a 
torment,  and  the  caustic  ineffectual. 

This,  stricture  in  the  middle  of  the  penis,  is  usually  accom- 
panied with  strictures  equally  formidable  near  the  bulb,  the 
immediate  cause  of  the  fistula.  These  are  to  be  cut  with  the 
knife,  rather  than  cauterised,  for  the  fistula?  of  the  perinaeum 
lead  directly  to  those  lower  strictures,  the  probe  or  directory 
passed  to  the  bottom  of  the  fistula,  touches  this  point ;  and  when 
the  fistula  is  to  be  laid  open,  though  it  would  be  wrong  where 
there  were  no  breach,  to  approach  the  urethra,  it  is  good  prac- 
tice, when  there  is  an  opening  in  the  urethra,  and  that  callous, 
to  make  that  opening  a  part  of  the  incision ;  to  pass  the  staff 
down  till  it  is  stopped  by  this  lower  stricture;  to  pass  the  direc- 
tory along  the  fistula,  till  it  almost  touch  the  staff;  to  observe 
well  the  direction  of  each,  and  to  cut  along  the  directory  till  the 
staff  is  laid  bare. 

4th,  To  attempt  any  surgical  operation  on  the  perinaeum, 
before  the  free  course  of  the  urine  is  restored,  would  be  but 
loss  of  labour,  and  a  wanton  destruction  of  parts  ;  and  the  mo- 
ment that  the  canal  is  free,  the  urine,  no  longer  disordering  the 
parts,  they  shew  a  tendency  to  heal,  while  the  bladder  itself 
seems  to  recover  its  powers.  I  h^ve  seen  a  patient,  whose  in- 
continence of  urine  was  such  as  to  wet  the  bed  incessantly,  and 


Of  the  Cure  of  Fistula.  223 

led  me  to  suspect  that  the  body  of  the  bladder  itself  was  per- 
forated, so  relieved,  by  cauterising  or  perforating  the  stricture, 
that  he  has  retained  his  urine  from  night  to  morning,  and  from 
morning  till  night,  passing  two  pounds  at  once.  When  the 
operation  ot  the  caustic  is  complete,  the  stricture  perforated, 
or  the  free  course  oi  the  urine,  b\  any  art  restored,  the  surgeon 
addresses  himself  to  the  new  and  arduous  duty  of  healing  the 
sores,  he  performs  now  on  the  fistula  in  perinaeo,  the  same 
radical  operation  that  he  would  on  the  fistula  in  ano,  i.  e.  he 
lavs  it  completely  open.  He  places  the  patient  as  for  the  opera- 
tion of  lithotomy  j  examines  all  the  openings  once  more  with 
the  probe,  and  sounds  their  depth,  and  remarks  their  relation 
to  the  urethra.  He  then  introduces  the  staff  down  to  the  stric- 
ture in  the  perinjeum,  and  gives  it  to  an  assistant  to  hold  ;  he 
next  passes  the  grooved  directory,  perhaps  a  little  bent,  along 
the  main  channel  of  the  fistula,  till  it  reach  the  stricture,  and 
almost  touch  the  staff;  he  then  either  runs  his  sharp  or  probe- 
pointed  bistoury,  as  he  thinks  best,  along  the  directory,  or  he 
cuts  with  a  common  scalpell,  till  he  at  once  lays  open  the  fistula 
and  cuts  the  stricture,  making  it  the  last  part  of  the  incision 
and  nicking  it  fairly.  He  has  now  laid  some  length  of  the  staff 
naked,  but,  to  be  assured  that  the  stricture  is  completely  un- 
done, he  pushes  the  point  ot  the  staff  through  the  incision  of 
the  perinseum  and  then  passes  it  into  the  bladder.  He  then 
withdraws  the  staff,  and  introducing  the  flexible  catheter,  or  a 
leaden  staff,  dresses  up  the  incisions  lightly,  and  perhaps  orders 
a  warm  stimulant  fomentation  of  chamomile  decoction  sharpen- 
ed with  sal  ammoniac  to  be  laid  over  the  parts  and  repeated 
from  day  to  day  to  keep  them  clean  and  in  a  pleasant  state  ; 
and  though  the  circumstances  of  the  case  should  have  forced 
him  to  lay  open  a  considerable  length  of  the  staff,  he  need  not 
be  dismayed,  for  we  frequently  see  several  inches  of  the  urethra 
(I  have  seen  full  three  inches  of  it)  regenerated,  or  rather  re- 
placed, from  the  growth  of  the  surrounding  parts. 

In  the  future  dressing,  though  I  do  not  altogether  forbid  the 
occasional  use  of  poultices,  I  do  not  approve  of  their  being 
continually  applied,  the  warm  bath  or  stimulant  fomentations 
are  much  to  be  preferred,  while  the  parts  will  always  be  found 
most  healthy  when  kept  dry  and  clean.  The  sponge  and  lint 
are  the  best  dressings.  The  callous  parts  may  be  touched 
with  caustic ;  and  when  the  granulating  process  languishes,  the 
parts  may  be  animated  with  red  precipitate  mixed  with  basili- 
con ;  spirit  of  turpentine,  when  not  applied  too  widely  so  as 
to  parch  the  parts,  but  touched  on  with  a  hair  pencil, is  often  re- 
markably useful ;  and,  the  alternating  these  stimulant  applica- 
tions with  poultices,  is  particularly  useful,  for  the   occasional 


224  Of  Paracentesis  Vesica. 

use  of  a  poultice  which,  if  continued,  relaxes  and  indisposes 
the  parts,  swells  them,  incrtases  their  stnsibilitv,  and  exposes 
them  to  the  operation  of  the  turpentine  or  precipitate.  Never 
let  such  sores  be  crammed  even  with  lint,  far  less  with  stimu- 
lant dressings,  but  let  the  dressings  be  laid  on  lightly  and  re- 
tained with  a  (T)  bandage.  The  flexible  catheter,  if  it  can  be 
retained,  promotes  the  cure  greatly  by  saving  the  parts  from 
the  excoriation  of  the  urine  ;  but  it  is  not  to  be  imagined  that 
the  lodging  of  the  catheter  within  the  bladder  prevents  alto- 
gether the  urine  tainting  the  parts,  for  every  time  the  bladder 
acts  (and  it  acts  more  frequently  and  more  irresistibly  when 
stimulated  by  the  catheter)  the  canal  of  the  urethra  dilates  so, 
that  while  much  ol  the  urine  flows  through  the  catheter,  some 
passes  by  the  side  oi  it  and  issues  at  the  pcrinaeum. 

The  bathing  the  parts  with  salt-water  contributes  to  prevent 
the  itching  and  preserves  them  cleanly  and  granulating,  and  the 
use  of  sea-bathing  and  exercise  often  contributes  to  the  final 
cure  of  sores  which  seem  altogether  callous  ;  but  it  is  not  to  be 
concealed  that  often,  after  the  cure  of  the  great  fistula,  and 
when  the  perinEeum  seems  entirely  restored  to  a  healthy  state  and 
the  urethra  to  be  free  of  obstruction,  one  small  point  continues 
perversely  open,  and  can  bv  no  means  be  healed  :  and  the  cir- 
cumstance of  the  patient  being  now  restored  from  the  most 
HK.lancholy  to  a  comfortable  situation  discourages  the  surgeon 
from  making  any  new  attempt. 


DISCOURSE  XV. 


OF  TOTAL  OBSTRUCTION  OF  URINE,  AND  THE 
OPERATION  OF  PARACENTESIS  VESICAE. 

SECTION    I. 

Preliminary  Observations. 

1  SHALL  conclude  this  subject  with  the  description  of  a 
desperate  operation,  which  is  yet  our  sole  resource  in  the  last 
stage  of  misery.  The  operation  of  paracentesis  is  less  frequent- 
ly resorted  to  as  the  means  of  saving  the  lives  of  young  and  im- 


Of  Paracentesis  Vesicce.  225 

prudent  people  ;  it  is  more  commonly  resorted  to  as  a  means  of 
prolonging  the  years  of  the  aged  and  infirm.  When  in  a  joung 
and  otherwise  healthy  man  it  happens,  that  by  a  blow  or  fall, 
the  perineum  is  injured  ;  or  when,  from  a  neglected  stricture 
and  a  sudden  suppression  of  urine  with  fever,  it  is  necessary 
to  perform  the  operation  of  paracentesis  vesicae,  the  scene  is  ve- 
ry distressing  ;  but  when  in  a  man  far  advanced  in  years,  the 
prostate  gland  has  been  long  diseased  and  has  occasioned  fre- 
qu  nt  obstruction  ;  when,  at  last,  the  bougie  gives  no  relief,  and 
the  catheter  cannot,  even  with  any  degree  of  force  or  rudeness, 
be  driven  into  the  bladder,  the  scene  is  not  less  affecting,  for 
this  swelling  of  the  prostate  is  a  disease  almost  peculiar  to  learn- 
ed and  sedentary  men ;  and  the  patient's  age,  infirmities,  and 
present  sufferings;  the  dignity  with  which  he  supports  them; 
the  presence  ot  his  family  depending  perhaps  on  the  survivancy 
of  his  offices,  and  the  melancholy  uhspersion  of  his  family, 
which  must  follow  his  death,  create  a  strong  sympathy.  His 
genius  and  literary  talents  give  us  a  particular  interest  in  his 
fate  ;  the  operation  is,  it  must  be  acknowledged,  but  a  tempora- 
ry resource,  yet  such  a  man  can  bear  to  linger  on  a  little  longer, 
'and,  with  his  family  around  him,  think  it  happiness. 

It  is  not  possible  to  refrain  from  alluding  to  a  melancholy 
scene,  which  returns  too  often  not  to  leave  serious  impressions, 
and  it  is  most  natural  to  feel  some  d.gree  of  anxiety  in  trying 
to  resolve  many  doubts  concerning  the  proper  conduct  of  the 
surgeon  in  circumstances  naturally  perplexing;  where  the  chief 
masters  in  surger)  deny  us  the  benefit  of  their  advice  and  counsel. 
"  1  must  own,"  says  one  of  the  first  surgeons  of  our  own  coun- 
trv,  "  that  I  have  not  seen  cases  enough  to  enable  me  to  give 
all  the  varieties  that  occasionally  happen,  and,  of  course,  all  the 
advantages  and  die-advantages  of  each  method.'"  But  are  those 
who  presume  to  teach,  entitled  thus  to  decline  giving  their  best 
advice  because  every  such  case  is  full  oi  difficulty  and  danger  ? 
Is  it  fair  thus  to  devolve  the  most  difficult  questions  in  our  art 
upon  the  individual  surgeon  perplexed  at  once  by  the  delicacy 
of  his  situation  and  the  selfish  reserve  of  authors,  whose  pro- 
vince it  is  to  lay  down  the  plain  line  of  his  duty  ?  Whatever 
presumption  there  may  appear  in  offering  to  explain  a  subject 
which  has  been  declined  bv  so  great  a  master  in  surgery  as  Hun- 
ter, I  cannot  but  reflect  that  this  is  an  operation  which'  may 
eventually  fall  to  the  lot  of  every  surgeon  to  perform  :  that  no- 
thing could  be  more  ungracious  on  the  part  ot  a  teacher  than  to 
devolve  on  every  young  man  the  difficult  task  of  going  unassist- 
ed through  a  long  process  ot  reasoning  upon  the  choice  of  in- 
struments or  rneth-  nded  with  the  imminent  risk  of  think- 

2F 


226  Of  Paracentesis  Vesica. 

ing  too  long,  or  of  acting  too  rashly :  I  cannot  but  recollect  that 
the  young  surgeon  coming  unprepared  to  such  an  operation, 
may  make  his  incisions  in  the  perinaeumdeep  and  wide,  and  yet 
miss  the  bladder,  and  find  no  better  way  of  retrieving  his  error 
than  by  performing  a  second  operation  by  incision  above  the 
pubis:  I  have  seen  this,  and,  to  my  utter  amazement,  have 
•seen  a  patient  so  mangled,  survive. 


SECTION    I. 

Of  Distention  and  Rupture  of  the  Bladder. 

When  we  speak  of  the  over-distention,  and  of  the  bursting 
of  the  urinary  bladder,  as  cause  and  effect,  we  are  guilty  of  a 
palpable  solecism  ;  nothing,  I  believe,  can  be  more  easily  proved, 
than  that  the  bladder  never  is  so  distended,  as  from  mere  exten- 
sion, to  give  way  ;  it  is  not  burst  by  dilatation,  but  is  inflamed,, 
becomes  gangrenous  in  one  spot,  and  then  yields.*  If  the 
bladder  can  be  so  distended,  without  rupture,  as  to  contain  ten 
pounds  of  urine,  if  it  be  so  distended  as  to  compress  the  intes- 
tines, fill  the  whole  abdomen,  and  rise  to  the  scrobiculus  cor- 
dis, without  rupture ;  if  it  be  thus  distended  by  the  third  day  of 
the  suppression,  and  yet  continues  entire  to  the  eighth  or  tenth 
day  ;  if  the  urine  begin  to  be  slowly  discharged  from  the  third 
day,  so  as  to  prevent  any  farther  accumulation,  how  can  it  be 
that  it  gives  way  from  mere  extension  ?  The  expression  over- 
distention  and  the  bursting  of  the  urinary  bladder,  is  so  com- 
mon, and  yet  so  deceitful,  that  I  hold  it  right  to  say  a  few  words 
on  the  dangers  of  distended  bladder,  which  will  at  once  explain 
the  difficulty. 

The  urinary  bladder,  which  naturally  holds  a  pound  and  a 
half  of  urine,  is  no  sooner  dilated  so  as  to  contain  two  pounds, 
than  uneasy  sensations  are  experienced  :  the  desire  of  passing 
the  water  is  very  strong,  and  if  the  desire  be  not  gratified,  if 
the  bladder  be  suffered  to  be  dilated  beyond  its  natural  state,  it 
loses  all  power,  and  becomes  paralytic.  The  desire  indeed 
continues,  and  the  efforts  are  renewed  in  painful  paroxysms, 
with  impatience  and  violence,  but  the  power  is  gone,  and  the 
bladder  continues  distending  more  and  more. 

When  it  becomes  so  enlarged  as  to  fill  the  whole  abdomen  ; 

*  Either  the  neck  of  the  bladder,  or  the  beginning  of  the  urethra,  certainly 
ruptures  in  fome  inftances ;  in  confequencc  of  which,  the  urine  becomes  extrava- 
fated  in  the  perineum.  The  impreflion  on  my  mind  is  very  ftrong  that  I  have 
€een  bladders  evidently  lacerated  from  over  diftcmion.     8. 


Of  Paracentesis  Vesica.  227 

when  it  reaches  the  scrobiculus  cordis,  and  can  rise  no  higher  ; 
when  the  distention  is  at  its  extreme,  and  neither  the  bladder  nor 
the  space  in  the  abdomen  can  receive  more,  the  general  pressure 
acts  like  an  expulsatory  power,  and  one  of  these  things  must  hap- 
pen :  either  the  bladder  must  give  way  and  lacerate,  which  it 
never  does,  so  equally  is  it  supported  by  the  pressure  of  the  sur- 
rounding parts  ;  or  its  orifice  must  dilate,  and  the  urine  begin  to 
flow.  The  urine  actually  begins  to  flow  from  the  third  day  of 
the  suppression,  and  whatever  urine  descends  from  the  kidnies 
is  evacuated  in  small  quantities  from  time  to  time. 

Now  this  gradual  and  dribbling  evacuation  of  urine,  which 
empties  the  bladder,  which  begins  with  the  full  distention  of  it 
and  continues  till  the  eighth  or  tenth  day,  or  till  the  bladder 
yields,  has  been  long  understood  by  good  surge ons,  and  has 
been  especially  named  by  the  French  writers,  <%  Urine  par  re- 
gorgement."  This  evacuation  of  urine,  proceeding  from  over- 
distention,  is  most  dangerous  and  deceitful.  The  friends  feli- 
citate themselves  that  the  urine  begins  to  flow;  they  commu- 
nicate their  information  to  the  physician,  which  he  is  too  apt  to 
believe ;  basins  and  cloths  wet  with  urine  are  easily  produced, 
but  the  patient  lies  unrelieved  ;  and  the  continued  distention  of 
the  bladder  is  followed  by  universal  inflammation  of  the  abdo- 
men :  the  insensibility  and  low  delirium  of  incipient  gangrene, 
are  mistaken  for  that  relief  which  was  expected  from  the  flow 
of  urine,  till  either  hiccup  comes  on,  and  the  patient  dies  of  fe- 
ver and  inflammation ;  or  the  urinary  bladder  actually  gives 
way,  and  the  acrid  urine  is  poured  out  into  the  cavity  of  the 
abdomen.  Cases  innumerable  of  this  description  are  to  be  found 
in  the  writings  of  the  older  surgeons  ;  the  quantity  of  urine  cor- 
responds so  well  with  the  quantity  of  drink,  that  the  physician 
is  apt  to  be  deceived  ;  and  Colot  tells  of  many  cases  in  which, 
while  they  believed  this  overflow  of  urine  to  be  an  incontinence, 
they  actually  mistook  the  distended  bladder  for  an  abdominal 
abscess,  and  made  appointments  to  open  it  by  incision. 

Let  no  surgeon  then  trust  to  the  reports  of  nurses  or  friends, 
nor  partake  of  their  inconsiderate  joy,  but  lay  his  hand  upon  the 
abdomen  and  tap  with  the  finger,  that  he  may  distinguish  the 
distended  bladder  and  the  fluctuation  of  the  urine. 

Since  then  the  bladder  suffers  no  farther  distention  from  the 
third  day,  why  should  it  burst  ?  Not  from  laceration,  for  \t  is 
supported  by  the  uniform  pressure  of  the  surrounding  viscera, 
and  the  general  tension  of  the  abdomen  :  not  by  yielding  sud- 
denly, for  it  is  distended  to  its  utmost  on  the  third  day  of  sup- 
pression, and  yet  seldom  gives  way  before  the  tenth :  not  by 
attenuation,  as  a  substance  merely  elastic  gives  way  fibre  after 
fibre,  or  bursts  suddenly,  for  the  bladder,  even  more  than  the 


228  Of  Paracentesis   Vesica* 

womb,  increases  in  thickness  in  proportion  as  it  is  distended. 
The  term  laceration  ne\cr  was  more  unfortunately  applied  than 
to  the  bladder;  for  when  there  is  a  breach  in  it,  we  find  upon 
dissecting  it  to  be  a  small  round  hole,  such  as  might  be  covered 
with  the  point  of  the  finger;  it  is  round  like  a  shot  hole,  with 
a  rough  and  ragged  margin,  in  short  the  .rupture  is  at  a  single 
spot,  not  longitudinal,  but  circular  ;  the  bladder,  and  all  the 
adjacent  viscera,  are  red  and  inflamed,  while  this  single  point  is 
black  and  mortified.* 

The  signs  of  death  are  not  merely  similar  to  those  of  pro- 
tracted labour  or  strangulated  hernia,  but  are  essentially  the 
same,  as  proceeding  from  the  same  cause.  While  the  bladder 
is  distending,  the  abdomen  feels  hard  and  firm,  and  the  tumour 
is  circumscribed  in  the  hypogastric  region :  when  the  bladder 
reaches  the  scrobiculus  cordis,  the  symptomatic  vomiting  comes 
on,  the  pulse  becomes  rapid,  the  belly  becomes  extremely  sensi- 
ble, and  the  patient  cannot  endure  the  gentlest  touch  :  and  soon, 
the  particular  swelling  of  the  bladder  is  concealed,  because  the 
abdomen  in  general  becomes  tumid  and  elastic,  like  a  drum, 
while  the  pulse  becomes  frequent  and  irregular,  the  mouth  is 
parched,  the  face  ghastly,  and  the  extremities  cold  j  and  when 
after  a  period  of  insensibility  or  low  and  muttering  delirium, 
the  patient  expires,  we  find,  upon  dissection,  the  bladder  deep 
coloured,  of  a  dusky  red,  thick  and  fibrous,  or  fleshy  :  often 
the  bladder  has  formed  adhesions  with  the  surrounding  parts, 
and  the  viscera  of  the  abdomen  are  very  generally  inflamt  d  before 
actual  gangrene  comes  on,  or  the  bladder  gives  way,  and  the 
patient  usually  expires  thus,  not  of  rupture  of  the  bladder,  but  of 
fever,  irritation  and  suppressed  discharge.  But  when  the  b'ad- 
der  has  actually  yielded,  its  rupture  is  accompanied  with  a  sense 
of  something  giving  way  within,  and  we  find  that  the  opening 
is  in  the  centre  of  the  fundus,  in  one  round  gangrenous  spot. 

To  those  who  imagine  that  the  extension  of  parts  in  the  living 
bodv,  is  like  that  of  the  dead,  an  attenuation  or  mere  dilatation  ! 
who  expect  to  find  the  bladder,  upon  dissection,  thin  and  trans- 
parent !  its  real  condition  must  appear  very  surprising.  The 
bladder  has  not  indeed  time  to  grow  bv  any  actual  deposition 
of  parts,  but  it  is  thukentd  by  the  fulntss  and  turgescence  of  its 
vessels,  and  by  extravasation  into  its  cellular  substance.  I  find 
always  the  veins  extremely  turgid,  the  muscular  fasciculi  big, 
fl  shy-like,  apparently  injected  with  blood,  (as  in  a  preparation 
where  the  bladder  is  injected  with  size,  till  the  size  is  ex'rava- 
sated  among  the  coats).  And  while  much  blood  is  extravasated 

*  Thefe  appearances  may  no  doubt  be  fometimesmet  with  on  diffe&ion,  but  it 
is  certain  that  the  bladder  is  occafionally  fairly  ruptured.     S. 


Of  Paracentesis  Vesicae.  229 

into  the  cellular  substance  of  the  coats  of  the  bladder,  some  ex- 
udes into  its  cavity,  thence  the  urine  is  always  deep  coloured, 
obviously  tinged  with  blood,  and  the  last  pound  of  urine  drawn 
off  either  by  the  catheter  or  trocar,  from  a  distended  bladdtr, 
is  as  thick  and  as  deep  coloured  as  coffee  grounds,  tinges  the  in- 
struments black,  and  is  extremely  fetid.  The  slow  and  gradual 
distention  of  any  living  part  is  invariably  accompanied  with  ac- 
tual growth  or  a  secretion  ot  new  parts  ;  sudden  extension  is  ac- 
companied only  with  a  turgescence  of  vessels,  a  fulness  of  blood 
in  the  part,  and  an  extravasation  into  the  cellular  substance  :  in- 
flamed viscera,  have  always  lrom  this  extravasation,  a  livid  ap- 
pearance :  a  strangulated  intestine,  and  a  distended,  and  conse- 
quently inflamed  bladder,  resemble  each  other  in  this  respect, 
and  though  such  parts  seem  gangrenous,  \et,  upon  macerating 
them  in  water,  the  blood  being  washed  out,  they  resume  their 
natural  complexion. 

That  these  several  stages  of  dilatation  of  the  bladder  may  be 
exemplified,  I  shall  briefly  recapitulate  the  circumstances  of  such 
a  case  :  A  woman  having  fallen  in  labour  on  Saturday  morning, 
the  head  of  the  child  descended  into  the  pelvis,  the  pressure  on 
the  urethra  prevented  any  urine  being  discharged,  the  head 
descended  lower  and  lower,  till  the  scalp  appeared,  on  Monday, 
protruding  through  the  orifice  of  the  vagina.  In  this  state  of 
suffering  the  woman  was  permitted  to  remain  till  Tuisda\  even- 
ing, when  she  was  delivered.  During  lour  complete  days  the 
pelvis  had  been  so  occupied  by  the  head  of  the  child,  that  the 
urine  could  not  be  discharged. 

The  catheter  was  never  introduced,  nor  did  the  medical  at- 
tendants make  even  the  slightest  inquir\  into  the  state  ol  the  ab- 
domen :  the  nurse,  when  changing  her  linens,  after  delivery, 
was  sensible  of  an  unusual  degree  ot  tulness,  and  the  patient 
expressed  her  desire  to  pass  her  urine,  but  she  lav  down,  the  de- 
sire, returned  again  at  the  distance  of  two  hours,  and  then  she 
passed  about  a  pint  of  urine,  next  da%  she  suffered  mueh  from 
pain  in  the  abdomen,  with  frequent  d,  sire  to  make  water,  which 
she  disiharged  in  tea-cup- fulls.  On  Saturda\ ,  (the  eighth  day  of 
her  distress)  the  ph\sician  who  attended  her  was  again  called  : 
her  belly  was  now  greatly  distended,  with  great  torments,  diffi- 
culty of  breathing,  and  oppression,  an  intense  thirst  which  she 
durst  not  indulge,  fever,  furred  tongue,  and  very  frequent 
pulse  :  about  an  hour  before  his  visit,  she  felt  something  rvith- 
in,  at  the  navel  crack,  with  great  pain.  For  thirty  hours  pre- 
ceding this  she  had  made  no  urine,  nor  did  she  pass  one  drop 
from  that  time  forward.  A  few  ounces  of  very  fetid  and  dark- 
coloured  urine  were  now  drawn  off  by  the  catheter,  and  on  the 
second  day  after,  she  died  delirious.    The  abdomen  was  found, 


230  Of  Paracentesis  Vesica:. 

upon  dissection,  universally  inflamed  :  the  bladder  had  given 
way,  and  the  opening  was  found  to  be  in  the  centre  of  the  fun- 
dus, of  a  circular  form,  and  with  a  black  and  gangrenous  mar- 
gin- 
Obstructed  urine,  hernia,  and  lingering  labour,  resemble 
each  other  so  entirely,  that  in  each  case  the  same  signs  indicate 
the  same  danger.  In  the  common  fate  of  the  patient  those  three 
cases  unhappilv  agree  but  too  well ;  delay  is  the  greatest 
danger,*  and  perhaps  I  have  not,  in  this  book,  announced  a 
maxim  of  more  importance  than  this  !  I  entreat  the  young  sur- 
geon to  beware  of  delay.  In  suppression  of  urine  it  is  most 
painful  to  see  that  the  needful  operation  is  usually  performed 
too  late,  that  the  patient's  resignation  avails  him  nothing,  and 
that  the  dexterous  operator  has  no  reward  for  his  skill  and  dex- 
terity. In  these  three  cases  it  requires  talents,  experience,  and 
a  spirit  of  observation,  to  conduct  the  patient  safely  :  to  give  a 
fair  chance  of  relief  from  the  powers  of  the  constitution,  without 
exposing  the  patient  to  danger,  by  delay  :  to  decide  whether  in 
cases  of  retention  of  urine,  the  abdomen  be  still  uninflamed,  so 
as  to  allow  time  for  the  good  effects  of  fomentations,  poultices, 
with  a  variety  of  trials,  to  force  the  passage  ?  or  whether  the 
danger  be  not  pressing,  requiring  the  bladder  to  be  relieved  at 
every  risk,  either  by  forcing  the  catheter  violently  through 
every  obstruction,  or  by  piercing  it  with  the  trocar  ?  This  I  am 
well  assured  of,  that  there  is  no  mode  of  operating,  no  kind  of 
danger  equal  to  that  of  delay.  It  were  better  that  the  surgeon 
cut  into  the  bladder  by  any  cruel  method  !  better  that  he  cut 
above  the  pubis,  or  make  his  wav  by  incisions  in  the  perinaeum, 
after  the  manner  of  the  lateral  lithotomy,  than  to  delay  the  ope- 
ration one  hour  beyond  that  in  which  the  signs  of  inflamed  ab- 
domen manifest  themselves  ;  for,  after  the  rudest  operations, 
the  patient  sometimes  survives,  but  from  delay  thousands  have 
been  lost.  It  is,  I  believe,  the  opinion  of  all  good  writers,  the 
maxim  respected  in  all  eras  of  our  science,  the  fair  deduction 
from  all  the  fatal  or  prosperous  cases  on  record,  that  we  should; 
in  retention  of  urine,  as  in  hernia,  operate  early. 

But  while  I  speak  thus  the  language  of  conviction,  and  repeat 
the  injunctions  of  the  most,  experienced  of  our  profession,  I  can- 
not be  without  some  anxiety,  lest  the  young  surgeon  should  be 
led  into  rash  measures.     I  know  it  to  be  true  that  few  have 


•  This  maxim  is  undoubtedly  correct  where  the  operation  is  or  will  benecefla- 
ry  ;  but  this  is  fo  feldom  the  cafe  that  in  ten  years  Default  performed  it  but  once, 
in  the  Hotel-Dieu,  of  Paris;  and  even  in  that  inftance,  he  afterwards  thought  it 
might  have  been  avoided.  Mr.  Abernethy  is  of  opinion  that  the  operation  ia 
rarely  if  ever  neccfiary,  that  the  remedies  above  mentioned  will,  in  almoft  every 
cafe,  procure  a  difcharge  of  the  urine.     S. 


Of  Paracentesis  Vesica,  231 

suffered  by  precipitation,  such  is  the  natural  aversion  to  opera- 
tions, and  the  reluctance  ot  friends!  while  in  my  own  limited 
practice  I  have  seen  many  victims  to  timid  measures  and  ope- 
rations performed  too  late  ;  yet  I  am  inclined  to  trespass  with 
one  observation  more,  which  may  serve  to  qualify  the  opinion 
I  have  laid  down. 

Although  the  greatest  danger  is  to  be  apprehended  from  in- 
flammation of  the  abdomen,  yet  the  whole  aspect  of  the  case  is  not 
to  be  ascribed  to  this  cause:  the  low  delirium,  trembling  pulse, 
or  even  hiccup,  do  not  portend  death  in  distention  of  the  blad- 
der so  absolutely  as  in  a  gangrened  limb  :  these  are  not  always 
signs  of  internal  gangrene,  often  they  manifest  themselves 
while  the  parts  continue  sound :  nor  does  every  degree  of  swell- 
ing of  the  belly,  vomiting,  and  faintness,  infallibly  indicate  abdo- 
minal inflammation  :  many  of  the  worst  signs  proceed,  in  some 
degree,  from  mere  irritation,  and  the  patient's  exhausted  state. 
In  retention  of  urine,  the  fulness  of  the  bladder  and  suppres- 
sion of  the  natural  discharge,  the  tossing  and  misery  of  the  pa- 
tient, from  desire  to  pass  urine,  and  the  ineffectual  endeavours 
to  introduce  the  catheter,  exhaust  him,  and  he  seems  in  the 
last  stage  of  the  suppression,  to  lie  almost  in  a  comatose  state. 
In  short  I  have,  in  the  course  ot  my  practice,  observed  that  in 
all  these  cases  delirium  comes  on  very  early,  in  consequence  of 
the  pain,  fever,  and  want  of  rest,  for  many  days  and  nights. 
The  inference  then  is  plain :  that  though  in  such  cases  nothing 
but  operating  can  save  the  patient's  life,  we  never  must  so  far 
prejudge  the  question,  as  to  say  he  is  beyond  the  reach  of  art! 
Every  surgeon  of  experience  must  have  observed,  that  in  dan- 
gerous distentions  of  the  bladder,  the  abdominal  pain  ceases, 
the  pulse  subsides,  the  tossing  of  the  patient,  and  all  the  signs 
of  indescribable  uneasiness,  vanish  as  soon  as  the  catheter  or 
trocar  is  forced  into  the  bladder  :  after  those  several  operations, 
the  delirium  goes  off,  the  senses  become  clear,  the  fever  abates, 
and  the  natural  sleep  is  restored. 

In  short,  the  worst  signs  are  no  sure  proofs  of  gangrene  ;  the 
patient  is  perhaps  exhausted  with  sickness,  irritation  and  pain  ; 
we  never  must  prejudge  the  question,  saving,  "  It  is  surely 
too  late  to  operate."     In  the  most  hopeless  cases,  let  the 

PATIENT    HAVE    HIS    CHANCE    FOR    LIFE. 

And  now  that  I  am  to  analyse  the  several  operations,  and 
teach  that  which  is  fittest  in  the  several  circumstances  to  be  per- 
formed, I  shall  say  a  few  words  on  a  subject  of  some  delicacy. 
The  talent  of  operating  is  not  merely  useful,  as  enabling  the 
surgeon  to  perform  safely,  a  dissection  which  is  not  without 
danger,  but  still  more  in  giving  him  perfect  possession  of  his 
own  mind.     The  degree  of  skill  we  have  or  suppose  ourselves 


232  Of  Puncturing  the  Bladder. 

to  have,  in  operating,  enters,  I  fear,  too  much  into  our  feeling6, 
when  considering  what  is  best  to  be  done  ;  lor,  in  difficult  cir- 
cumstances, a  man  timid  and  unskilful  in  operation  will  be  apt 
to  linger  and  hesitate ;  a  man  bold  and  conscious  of  operating 
well,  especially  if  not  familiar  with  practice,  will  be  apt  to  hur- 
ry on  with  precipitation,  to  the  most  decided  measures;  but  a 
man  who  is  familiar  with  scenes  of  this  nature,  and  has  both 
performed  many  operations,  and  has  studied  well  the  prognos- 
tics of  danger  or  satety,  will,  if  he  be  at  the  same  time  a  fear- 
less operator,  proceed  at  once  with  resolution  and  caution,  will 
neither  hurry,  nor  delay  too  long,  the  measures  which  he  thinks 
necessary  for  the  patient's  safety  ;  and  though  no  modest  nor 
ingenuous  man  will  ever,  upon  a  retrospect,  be  entirely  satis- 
fied with  his  own  conduct,  even  when  most  successful,  yet  one 
thus  qualified  at  once  to  reflect  deliberately,  and  act  intrepidly, 
will,  upon  the  severest  scrutiny  into  his  past  conduct,  find  little 
reason  for  self-reproach.  I  do  regard  skill  in  operating  as  of 
the  utmost  importance  in  giving  the  surgeon  perfect  self-pos- 
session :  a  bad  operator  will  hesitate,  in  the  most  simple  cases, 
while  a  good  and  dexterous  operator,  like  a  man  skilful  in  the 
use  of  weapons,  will  not  enter  rashly  into  difficulties,  but  be- 
ing engaged  from  conviction,  will  bring  himself  through  with 
courage.  Let  every  >oung  man  then  endeavour  to  become  a 
dexterous  operator,  for  that  will  help  to  make  him  a  judi- 
cious  SURGEON. 

SECTION    III. 

Of  the  several  Methods  of  puncturing  the  Bladder. 

If  we  are  entirely  in  any  case  to  join  pathology  with  surgery,  to 
reason  from  the  constitution  and  nature  of  the  parts,  and  from  the 
acknowledged  dangers  of  operation,  to  any  practical  conclu- 
sions, it  must  be  in  the  present  case,  where  innumerable  dis- 
sections instruct  us  in  the  causes  of  death.  Having  established 
the  fact,  that  in  cases  of  retention  of  urine  the  patient  dies  from 
no  other  cause  than  inflammation  of  the  abdomen,  let  us  see 
what  assistance  this  theory  will  give  in  deciding  the  main  ques- 
tion, "■  Which  is  the  least  dangerous  method  of  tapping  the 
bladder?"  First,  If  we  make  our  incision  above  the  pubis, 
and  strike  the  trocar  from  that  point  into  the  bladder,  we  cut 
parts  contiguous  to  the  peritonaeum  already  inflamed.  Se- 
condly, If  we  cut  from  the  perinjeum,  with  incisions  resembling 
those  of  lithotomy,  we  make  deep,  unnecessary  wounds  in  a 
part  of  the  bladder  which,  though  lodged  in  the  pelvis,  some- 
times extends  its  inflammation,  as  in  Chesselden's  first  experi- 


Of  Puncturing  the  Bladder.  233 

ments,  to  the  cavity  of  the  abdomen.  Thirdly,  If  we  strike 
the  trocar  skilfully  into  the  same  part  into  the  perinaeum,  with- 
out such  preliminary  incisions,  the  risk  of  inflammation  is 
greatly  lessened;  and  if  we  pass  the  trocar  from  the  rectum  in- 
to the  bladder,  we  carry  it  through  no  thickness  of  parts,  but 
transfix  only  two  membranes:  it  is  "like  a  stroke  in  the  wa- 
ter:" and  the  danger  of  inflammation  is  exceedingly  small. 
This  slight  index  of  the  principles,  according  to  which  1  mean 
to  reason,  will  enable  my  reader  to  accompany  me  in  the  fol- 
lowing critical  review  of  the  several  mcUiods  of  operating: 
perhaps  it  will  enable  him  to  anticipate  many  of  my  conclu- 
sions ;  it  will  surclv  incline  him  to  adopt  a  mode  of  puncturing 
the  bladder  very  different  from  that  in  common  use. 

1'IRST    METHOD. 

The  most  common  operation,  because  the  most  obvious,  is 
to  penetrate  from  above  the  pubis.  Every  ignorant  tyro, 
though  unable  to  strike  the  bladder  from  any  other  part,  is  able 
to  plunge  the  trocar  into  it,  at  a  point  where  he  feels  the  fluctu- 
ation so  plainly :  that  superficial  objection  of  the  danger  of 
wounding  the  peritonaeum,  so  oltcn  urged  against  this  method, 
is  indeed  of  no  importance ;  there  is  no  danger  of  wounding 
the  peritonaeum,  for  the  bladder,  when  greatly  distended,  reaches 
high  above  the  navel,  carries  the  peritonaeum,  of  course,  belore 
it,  and  exposes  a  space  of  several  inches,  in  which  we  may  per- 
form our  incisions  without  incurring  this  kind  of  danger.  But 
the  abdomen  is  inflamed ;  the  preliminary  incisions,  which  pre- 
pare for  the  introduction  of  the  trocar,  pass,  in  a  gross  old  man, 
through  several  inches  of  fat  and  cellular  substance:  the  inci- 
sions must  be  wide  in  proportion  to  their  depth  :  the  canula  is 
no  sooner  lodged  here  than  it  is  displaced,  in  some  degree,  by 
the  contraction  of  the  bladder,  which,  when  emptied,  subsides 
under  the  pubis:  the  canula  stands  so  obliquely  that  the  urine 
never  flows  with  ease  but  by  running  out  upon  the  wound,  and 
by  being  injected  among  the  cellular  substance,  it  causes  the 
wound  to  inflame,  the  wound,  by  its  proximity  to  the  inflamed 
peritonaeum,  soon  mortifies,  and  thus,  notwithstanding  the  tem- 
porary relief  produced  by  the  emptying  ot  the  bladder,  the  pa- 
tient dies  on  the  third  or  fourth  day. 

Those  who  have  been  forced  by  fatal  experience  to  condemn 
the  puncture  above  the  pubis,  have  entered  into  no  investiga- 
tion, and  have  not  always  been  able  to  assign  a  cause  lor  their 
ill  success  ;  but  it  is  well  known  that  the  wound  is  apt  to  gan- 
grene, the  operation  is  so  easy  that  nothing  but  exprrience  ot 
its  ill  consequences  could  prevent  its  being  universally  pr«  ler- 

'2  G 


234  Of  Puncturing  Hie  Bladder. 

red  :  but  the  unfavourable  issue  ot  the  operation  is  now  so  uni- 
versillv  acknowledged,  that  even  the-  difficulty  and  deep  inci- 
sions in  the;  pcrinseum  are  preferred.* 

SECOND    MLTHOD. 

To  perforate  the  bladder  with  a  trocar,  from  the  perinamm, after 
making  incisions,  lik*-  tno-.eof  lithotomy,  is  the  sole  m<  thod  now 
mentioned  in  sv  ste.nsot  surgery,  a  harsh,-  ruel,  and  dangerous  o- 
peration.   For  when  die  surgeon  is  to  make  "incision  in  the  per  i- 
nccum,  an  inch  and  a  half  in  length,  at  the  commencement  of  the 
membranous  pur  t  oj  the  urethra,  and  continuing  it  toward*  the  anus 
in  a  hue  parallel  xvith,  but  at  least  half  cm  inch  distant  from  the 
raphe  pcrinan  .'"   he  has  to  operate  according  to  precepts  so  in- 
consistent with  the  actual  relations  ol  the  parts,  so  unintelligible 
to  one  who  is  an  anatomist,  and  so  nugatory  to  one  who  is  not, 
that  he  must  cut  at  random  :  having  made  deep  incisions  in  the 
pi  rinaeum,  he  no  sooner  begins   "  to  search  tor  the  bladder  with 
his  finger  in  the  bottom  of  the  wound,"  than  he  directly   en- 
counters the  enlarged  body  of  the  prostate :   If  he   understands 
what  he  feels,  and   dissects   backwards  till  he  distinguishes  the 
bladder  itself,  he  actually  reaches  that  part  of  the  bladder  which 
lies  upon  the  re<  turn  ;  (viz.  the  space  betwixt  the  visculae)  he 
arrives  exactly  at  the  same  point  which  he  touches  in  perfora- 
ting from  the   rectum,  and  no  one  will  deny  that  he  might  per- 
forate with  more  security  and  less  pain  from  the  rectum,  through 
its  thin  walls,  than  from  the  perinseum  by  these  incisions:  But, 
having  made  his  way  to   the  gland,  he  points  his  trocar  (which 
is  usually  too  short  for  any  purpose,  and  not  at  all  appropriated 
for   this)  directly  upon  the   gland,  drives  it  deep   into  its  sub- 
stance, and  no  urine  flows,  or  flows  only  when  both  trocar  and 
canula  are  withdrawn. — How  this  happens  it  is  not   difficult 
to  conceive :  M  An  old  man  who,  for  the  last  Twelve  or  fourteen 
years  of  his  life,  was  subject  to  occasional  difficulty,  was  at  last 
affected    with  entire  retention,  so  that  for  five   davs   preced- 
ing the  operation,  he  had  not  passed  one  drop  of  urine :  all  at- 
tempts to  introduce  the  catheter,   or  give  relief  by  passing  bou- 
gies, were  in  vain,  the   tumid  bladder  was  felt  above  the  navel, 
he  had  continual  straining    to   avoid    his   urine,  with  sickness, 
thirst,  and  a  feverish  pulse.      But  in  his  disease,  nor  in  his  prts- 
ent  distress,  there   was  nothing  peculiar  or   worthy   of  notice. 
A  young  surgeon  performed  the  operation  ol  puncture  in  peri- 
nseo  by  ail  the  usually  prescribed  rules.       After  .dissecting  into 

*  Mr.  Ahernethy  has  performer'  this  operation  fevera]  tinvis  with  fuccefs,  and 
prefers  it  to  any  other  tor  relieving  the  bladder  under  thefe  circumlta'nces.     S. 


Of  Puncturing  the  Bladder.  235 

the  hollow  of  the  pelvis,  he  struck  his  trocar  deep,  but  upon 
withdrawing  the  stillct,  no  urine  flowed,  it  was  only  when  he 
was  withdrawing  the  trocar  also,  that  a  little  uiine  ran  out  ; 
nothing  intimidated  by  this  ill  success,  he  struck  his  trocar  once 
mure,  now  tht  urine  flowed  freely;  the  canula  was  left  in  its 
place,  the  urine  continued  to  be  discharged,  but  the  abdomen 
inflamed  and  the  man  died." 

44  Upon  dissecting  the  body,  the  first  thing  that  could  be  ob- 
served was  the  fundus  of  the  bladder  hanging  flaccid  upon  the 
point  of  the  canula,  which  projected  some  inches  into  itscavit)  ; 
upon  opening  the  bladder,  the  canula  was  seen  in  its  place  ; 
upon  withdrawing  ihe  tanula  and  cutting  out  tht  parts  lvom  the 
pelvis,  laying  them  on  the  dissecting  board,  and  investigating 
the  inner  surface  ol  the  bladder,  not  the  slightest  mark  ot  punc- 
ture was  to  be  found;  so  that  had  not  the  trocar  been  seen  in 
its  place,  upon  opening  the  abdomen,  no  one  could  have  believ- 
ed that  it  had  penetrat«  d  !" 

This  case  1  noted  down  as  peculiarly  instructive  ;  an  opera- 
tion essentially  bad  was  performed  in  a  manner  so  rude  and 
barbarous,  that  a  coroner's  inquest  might  have  taken  cogni- 
zance ot  the  affair:  This  culpable  homicide  was  a  consequence 
ol  the  same  ignorance  ot  anatomy,  which  makes  many  an  ope- 
ration for  the  stone  miscarry  :  There  is  no  wonder  it  a  surg<  on 
who  would,  it  he  were  cutting  for  the  ston^,  niek  the  urethra 
sevtral  times  betore  he  was  sure  ot  having  divided  it,  strikes 
his  trocar  twice  before  he  punetures  the  bladdci  :  This  gentle- 
man directly  encounti  r«  d  the  diseased  prostate  without  knowing 
it !  He  not  onlv  plunged  into  its  subs-tame,  but  that  trans\  t  rse- 
ly,  so  as  to  transfix  the  gland  ;  lor  the  point  of  this  canula  being 
buried  in  the  farther  side  ot  the  gland,  no  urine-  flowed  when 
he  first  withdrew  the  stillet !  but  while  he  was  withdrawing  the 
canula,  after  he  had  drawn  its  point  irom  the  farther  lobe  of 
the  gland,  and  betore  it  was  withdrawn  altogether,  it  received, 
in  passing  from  side  to  side,  a  tew  drops  ot  urine  which  flow- 
ed out:  Ihe  second  time  he  struck  in  his  trocar,  it  neither 
passed  deep  behind  the  gland,  which  is  the  proper  intention  in 
this  method,  nor  into  the  substance  ot  the  gland,  and  through 
its  thickness  into  the  cavity  of  the  bladder,  as  usualh  happens, 
but  directly  onwards  in  the  line  of  the  natural  canal,  first 
through  the  urethra,  and  then  through  the  centre  oi  the  gland. 
Thus  it  happened,  that,  alter  death,  no  wound  of  the  trocar 
could  any  where  be  found  :  as  for  the-  death  ol  the  patient  there 
cannot  be  a  matter  ol  wonder. 

There  is  no  more  heinous  fault  than  that  of  practising  surgery 
without  a  knowledge-  ol  anatomy^  unless  it  be  that  ot  studying 
anatomy  independent!)  ol  pathology,  and  applying  the  descrip- 


256  Of  Puncturing  the  Bladder* 

tions  of  parts  in  the  sound  body,  to  the  same  parts  in  a  state  of 
disease.  The  effect  of  the  enlargement  of  the  prostate  gland, 
upon  our  operations,  has  (as  I  know  by  fatal  examples)  been 
but  little  studied.  The  plan  1st,  of  enlarged  prostate  is  very 
simple,  I  have  represented  in  a  true  drawing  the  enlarged  pros- 
tate which  in  truth  fills  all  the  lower  part  of  the  pelvis,  and  pre- 
sents itself  to  the  surgeon,  so  that  without  a  perfect  conception 
of  its  form,  and  actually  feeling  it  with  the  finger,  he  can  per- 
form no  operation  without  blundering.  The  extent  of  the  en- 
larged gland  is  designated  by  the  figures  (a  a  a)  ;  the  contracted 
bladder  (for  it  thickens  and  corrugates  in  proportion  as  the 
gland  grows)  is  marked  (b  b)  ;  the  membranous  part]  of  the 
urethra  is  marked  (c)  ;  while  the  original  and  natural  size  of 
the  prostate  is  marked  in  dotted  lines  ;  and  let  it  be  observed 
that  as  the  gland  enlarges,  the  space  (d)  betwixt  the  ureters  and 
vesiculae  seminales  of  the  two  sides,  is  increased  ;  by  being  re- 
moved from  each  other,  they  leave  a  wider  space  open  to  the 
puncture  of  the  trocar,  so  that  they  cannot  be  wounded,  and 
though  it  were  not  so,  the  wounding  of  the  vesiculae,  though  it 
has  been  represented  as  a  mighty  objection  to  the  puncture  from 
the  rectum,  is  none :  the  vesiculae  would  heal  as  easily  as  any 
other  part,  and  the  vasa  deferentia  would  re-unite  (unless  indeed 
they  were  cut  across),  as  easily  as  the  bladder  re-unites,  but 
this  is  a  question  of  no  importance,  the  operation  is  performed 
in  people  advanced  in  years  and  ruined  in  constitution,  and  the 
question  is  not  about  saving  the  organs  of  procreation  from  any 
slight  injury,  but  about  saving  life.  The  plan  2d,  presents  the 
same  parts  in  a  vertical  section.  The  staff  is  stopped  at  (a),  in 
the  membranous  part  of  the  urethra,  by  a  stricture.  The  gland 
(bb)  is  represented  as  enlarged,  filling  the  lower  and  fore-part 
of  the  pelvis,  and  compressing,  in  some  degree,  the  rectum. 

That  the  surgeon  can  hardly  perforate  behind  the  diseased 
gland  through  the  body  of  the  bladder  itself,  except  by  a  very 
deep  and  dangerous  dissection,  is  what  I  have  always  conjec- 
tured, when  observing  the  size  of  the  diseased  gland  ;  every 
operation  I  have  since  witnessed  has  contributed  to  strengthen 
a  suspicion,  which  has  been  absolutely  confirmed  by  a  miscar- 
riage more  extraordinary  and  less  pardonable  than  that  which  I 
have  just  mentioned;  for  though  it  is  unpardonable  to  begin  the 
operation  by  incisions  in  the  perinaeum,  without  introducing 
the  finger  in  ano,  to  feel  the  condition  and  size  of  the  gland, 
yet  nothing  can  exceed  the  folly,  in  actually  perforating  from 
the  rectum,  of  having  the  finger  introduced  for  the  purpose  too 
of  guiding  the  trocar,  without  estimating  the  extent  of  the 
gland,  or  choosing  a  trocar  sufficiently  long. 

A  gentleman  being  resolved  to  practise  the  newest  piece  of 


P   2.36. 


Flan  J .  dif*af*i  firstatt. 


Of  Puncturing  the  Bladder.  237 

surgery ;  viz.  puncturing  from  the  rectum  ;  used,  in  spite  of 
every  remonstrance  on  my  part,  a  common  trocar,  hardly  more 
than  three  inches  long !  a  common  trocar  lor  tapping  the  belly 
in  ascites  !  The  consequence  was  most  lamentable,  for  the  in- 
strument being  buried  in  the  substance  of  the  enlarged  gland, 
not  one  drop  of  urine  flowed  ;  the  trocar  and  canula  were  both 
withdrawn,  and  the  operation  of  puncturing  above  the  pubis 
performed. 

THIRD    METHOD. 

In  tapping  the  bladder  from  the  perinseum  without  previous 
incisions,  the  puncture  is  pertormed  on  the  broadest  part  of  the 
bladder,  where  it  lies  under  the  arch  ol  the  pubis;  the  point  of 
the  trocar  enters  about  the  level  of  the  urethra,  where  there  is 
little  of  the  diseased  gland  ;  to  hit  the  bladder,  not  from  be- 
hind the  gland,  but  from  its  fore  part  thus,  is  as  easy  as  to 
plunge  into  its  fundus  from  above  the  pubis  :  no  tyro  could  miss 
the  stroke  ;  if  the  surgeon  keep  close  to  the  arch  of  the  pubis, 
without  actually  encountering  the  bone  with  his  trocar,  he  can- 
not fail  to  strike  the  bladder  lair. 

For  this  operation  the  patient  is  to  be  laid  as  for  lithotomy, 
on  the  side  of  his  bed,  on  his  back,  the  knees  raised  and  sepa- 
rated by  assistants,  and  the  heels  placed  firm  upon  the  bed,  near 
the  buttocks,  or  held  by  the  assistants  on  each  side  ;  a  skilful 
assistant  is  to  compress  the  abdomen  with  both  hands,  so  as  to 
depress  the  bladder  and  keep  it  steady. 

The  surgeon  is  to  imagine  a  line  drawn  in  the  direction  of 
the  transverse  muscle;  i.  e.  from  the  anus  to  the  tuber  ischii, 
and  the  centre  of  the  triangle  which  that  line  forms  with  the  arch 
of  the  pubis,  or  a  little  higher  than  the  centre,  is  the  point  at 
which  the  trocar  is  to  enter. 

The  catheter  is  to  be  introduced  as  far  as  it  will  pass,  to  pre- 
vent any  harm  to  the  urethra,  and  to  direct  the  trocar  ;  the  lore- 
finger  of  the  left  hand  is  to  be  passed  deep  into  the  rectum,  to 
feel  the  bladder  or  the  swelled  gland,  and  to  enable  the  sur- 
geon both  to  judge  of  the  relation  of  parts,  and  to  keep  them  in 
some  degree  steady  ;  the  trocar,  which  must  be  long,  slender 
and  a  little  curved,  must  have  a  big,  round  handle,  and  the 
surgeon  taking  the  handle  in  the  palm  of  his  right  hand,  and 
laying  the  fore-finger  along  the  canula  to  steady  it,  is  to  enter 
it,  at  first,  directly  into  the  part  inclining  a  very  little  upwards, 
and  to  carry  it  on  slowly,  steadily,  and  without  fear,  until  he 
feel  it  in  the  open  cavity  of  the  bladder,  when,  by  withdrawing 
the  trocar,  the  urine  will  flow  out. 

"  The  operation  of  paracentesis,  though  it  be  no  more  (says 


238  Of  Puncturing  the  Bladder. 

Dionis)  than  a  simple  puncture,  requires  on  the  part  of  the  sur- 
ge on,  a  perfect  knowledge  oi  anatomy,  and  ol  tne  relation  of 
parts,  both  to  conduct  his  instrument  directly  into  the  bladder, 
and  to  avoid  encountering  any  important  parts  ;  it  is  indeed 
alarming  to  a  surg-on  little  versed  in  anatomy,  though  «  xtrc-me- 
ly  easy  to  those  who  are."  To  this  opinion  we  very  wil'ii.gly 
subscribe;  il  the  operation  be  at  all  perplexing,  it  must  be  to 
those  only  who  are  :gnorant  of  anatomy,  but  I  \\d\c  gone  a  itep 
farther  in  protesting  that  it  can  be  difficult  to  no  one  who  has 
discretion  and  courage  ;  and  that  it  is  as  easy  to  strike  the 
br  >ad  anterior  suriac  ot  the  bladder  under  the  arch  of  the  pu- 
bis, as  to  plunge  into  it  from  above. 

FOURTH    METHOD. 

When  the  catheter  is  obstructed  and  can  by  no  means  be  for- 
ced into  the  bladder,  what  is  the  difficulty?  some  stricture, 
amounting  almost  to  obliteration  of  the  membranous  part  of  the 
ur>  thra,  or  more  frequently  an  induration  of  the  prostate. 
Wbtre  is  the  catheter  arrested  ?  always  near  the  point  of  the 
prostate  gland  ;  it  stops  just  where  the  point  of  the  catheter 
passes  the  finger  laid  on  the  perinseum,  and  at  that  place  where 
it  is  felt  upon  introducing  the  same  finger  into  the  rectum.  If 
the  catheter  could  be  thrust  through  this  obstruction  and  driven 
into  the  bladder,  even  at  the  expense  of  some  violence,  and 
much  blood,  would  such  rudeness  be  fatal  ?  by  no  means,  such 
an  operation  would,  on  the  contrary,  give  present  relief. 

If  either  by  thus  pushing  on  the  catheter  with  some  lacera- 
tion of  parts  within,  or  if,  by  a  small  incision  in  the  perinseum, 
the  course  of  the  urethra  could  be  recovered,  and  a  probe  pas- 
sed along  it,  or  the  common  grooved  directory,  or  any  such 
instrument  introduced,  would  such  injuries  be  at  all  equal  to 
those  I  have  enumerated  ?  or  would  the  danger  of  inflamma- 
tion, when  the  neck  and  natural  opening  of  the  bladder  were 
thus  forced,  be  at  all  comparable  with  these  dangers,  which 
must  accompany  a  wound  of  its  body,  whether  from  above  the 
pubis,  or  from  behind  the  prostate  gland  ?  surely  not.  If  sur- 
geons would  but  condescend  to  make  themselves  correctly 
masters  of  this  piece  of  anatomy ;  if,  having  passed  the 
male  catheter  as  far  as  it  could  go,  they  would  then,  with  a 
small  incision,  seek  out  the  obstructed  part  of  the  urethra,  they 
would  be  able  either  to  help  on  the  catheter  with  the  probe,  or 
to  dilate  the  urethra,  or  to  force  the  prostate  gland,  bv  passing  a 
female  catheter  straight  on  from  the  point  where  the  male  cath- 
eter stops;  and  a  wound  so  bloodless,  so  far  from  the  pelvis  or 
abdomen,  so  nearly  resembling  the  thrusting  on  oi  the  catheter. 


Of  Puncturing  the  Bladder*  239 

affecting  merely  the  neck  of  the  bladder,  might  be  resorted  to 
early,  and  many  precious  lives  be  saved. 

FIFTH    METHOD. 

If  there  be  a  method  which  may  be  put  in  competition  with 
this,  it  is  that  of  puncturing  from  the  rectum.  I  am  not  indeed 
ignorant  that  this  way  of  reaching  the  bladder  lies  under  the 
formal  protest  of  some  writers,  but  they  are  of  those  who  have 
written  about  surgery  by  conjecture,  whose  authority  stands  on 
no  other  grounds  than  reasoning  ;  and  what  reasoning  can  dis- 
cover anv  thing  sup  rior  in  the  common  and  rude  operation  of 
making  incisions  in  the  perinseum,  when  compared  with  this  of 
puncturing  from  the  bladder?  The  surgeon  must  have  little 
confidence  in  either  his  reasoning  or  experience,  who  says, 
"  we  shall  therefore  dismiss  this  method  (viz.  the  puncture 
"  from  the  rectum)  without  farther  consideration."  Yet  this  is 
wisely  said,  for  the  question  will  bear  no  reasoning  ;  first  an 
operation  is  described,  in  which,  after  incisions  long  and  deep 
in  the  perineum,  a  trocar  is  plunged  into  the  bladder,  some- 
times through  the  diseased  prostate,  but  more  frtqucntU  be- 
hind that  gland,  if  the  design  ol  the  operation  be  truly  fulfilled  j 
and  next,  the  puncture  from  the  rectum  is  protested  against  be- 
cause the  trocar  m  iy  wound,  forsooth,  the  vesiculae  stminales, 
when  in  fact  the  operation  by  incisions  in  the  perin  eum  brings 
the  trocar  to  that  very  point,  where,  if  struck  from  the  rectum 
it  must  enter. 

The  project  of  puncturing  the  bladder  from  the  rectum,  ori- 
ginated, like  many  valuable  inventions,  in  accident.  The  sur- 
geon introducing  the  finger  into  the  rectum,  felt  the  bladder 
distinctly;  and  to  use  the  expression  of  one  gentleman,  (who 
hovvever  unfortunately  neglected  the  hint,)  "  the  bladder  was 
felt  so  distinctly,  and  the  fluctuation  of  urine  was  so  obvious, 
that  the  surgeon  was  conscious  he  could  have  struck  a  lancet 
into  it  as  easily  as  into  a  vein."  Others  more  confident  did 
actually  strike  the  trocar  into  the  bladder,  through  the  walls  of 
the  rectum,  and  draw  off  the  urine  very  easilv,  and  had  the 
happiness  to  find  that  the  canula  could  be  retained,  and  that 
when,  by  accident  it  slipped  out,  the  perforation  still  continued 
open,  so  as  to  permit  the  urine  to  pass,  and  yet  the  contraction 
of  the  levator-ani  muscle  shut  the  opening  like  a  sphincter,  so 
that  the  urine  never  flowed  except  when  the  bladder  was  suffi- 
ciently full  to  excite  desire,  and  when  the  natural  course  of  the 
urine  was  restored,  the  opening  betwixt  the  bladder  and  rectum 
spontaneously  healed.  With  such  advantages,  with  no  import- 
ant parts  endangered  in  the  operation,  this  method  is  unfortu- 


240  Of  Puncturing  the  Bladder. 

nately  limited  !  it  was  once  practised  very  happily  in  a  child, 
whose  urine  was  obstructed  by  a  stone  sticking  near  the  glans 
penis  ;  it  has  been  practised  also  with  the  best  effects  in  young 
men,  who  have  had  the  urethra  burst,  by  falls  upon  the  peri- 
naeum  ;  but  it  is  to  be  preferred  chiefly  in  cases  where  the  ob- 
struction is  temporary,  and  when  we  have  reason  to  hope  that 
the  natural  course  of  the  urine  will  be  soon  restored  ;  but  in 
the  most  frequent  and  most  distressing  of  all  cases,  the  disease 
of  the  prostate,  this  method  I  fear  cannot  be  of  use.* 

SIXTH    METHOD    OF    FORCING    THE    CATHETER. 

The  disease  of  the  prostate  gland,  which  embitters  so  often 
the  last  stage  of  life,  of  which  Dr.  Fothergill,  and  many  men 
eminent  in  literature  and  science,  have  died,  is  that  chiefly  in 
which  the  operation  of  paracentesis  is  required,  a  wretched 
resource  which  only  prolongs  life. 

The  surgeon  is  aware  of  his  patient's  condition,  for  he  has  at- 
tended him  for  years,  and  witnessed  the  slow  but  unceasing 
progress  of  this  malady  ;  he  has  frequently  been  called  to  attend 
him  in  slighter  obstructions  of  the  urine,  and  has  remarked  the 
flattened  form  which  the  faeces  take,  he  has  heard  the  feelings 
of  the  patient  often  described,  who,  along  with  a  continual  sense 
of  pressure  and  fulness  in  the  pelvis,  has  an  unceasing  desire 
to  pass  his  urine  ;  when  attempting  to  give  him  relief  by  the 
bougie,  he  has  remarked  the  point  of  it  turned  backwards,  and 
when  next  he  has  betaken  himself  to  the  catheter,  and  forced  it 
through  the  passage,  he  has  felt  with  the  finger  in  ano,  that  the 
prostate  gland  filled  the  pelvis,  and  compressed  the  rectum  ;  he 
has  witnessed  the  frequent  returns  of  these  paroxysms  of  parti- 
cular difficulty,  and  lived  in  the  continual  fear  that  the  obstruc- 
tion would  in  the  end  be  final  and  insurmountable.  At  last, 
from  some  unfortunate  fulness  of  the  bladder,  from  some  acci- 
dental cold,  from  piks  affecting  the  rectum,  and  producing  irri- 
tation and  irregular  spasms  in  these  parts,  the  urine  is  retained  ; 
all  attempts  to  introduce  the  bougie,  or  to  insinuate  the  flexible, 
or  force  in  the  rigid  catheter,  are  vain ;  fomentations,  poul- 
tices, and  stimulant  embrocations,  produce  no  relief  ;  the  blad- 
der, contracted  by  long  diseases,  bears  the  distention  very  dif- 
ficultly ;  though  it  is  but  slightly  distended,  the  anguish  is  intol- 
erable, the  abdomen  inflames,  and  fever  comes  on,  with  parched 
tongue  and  rapid  pulse,  and  thirst  which  cannot  be  indulged. 

•  Mr.  Home  relates  four  cafes  in  which  he  performed  this  operation  ;  in  one 
inftancc  fome  inconvenience  enfued  from  the  paffage  of  the  urine  through  the 
rectum.     See"  Homton  Strictures,"  vol.  %.  c.  7.  p.  319.     S. 


Of  Puncturing  the  Bladder.  241 

Then  the  surgeon  is  sorely  tempted  to  do  a  thing  which  will 
give  instant  relief,  but  which  is  yet  attended  with  unequivocal 
danger !  he  feels  that  he  could  drive  the  catheter  forward  into 
the  bladder,  but  not  perhaps  in  the  regular  tanal,  nor  without 
tearing  through  the  membranous  part  of  the  urethra,  and  plung- 
ing through  the  substance  oi  the  diseased  prostate.  Authorities 
for  such  a  practice  we  have  none,  or  next  to  none  ;  unless  it  be 
an  authority  for  this  desperate  plunge,  that  the  case  is  desperate, 
and  very  desperate  the  operations  to  which  we  must  next  re- 
sort. 

Mr.  Ware,  in  dissecting  a  patient  who  had  died  of  this  dis- 
ease, having  begun  his  dissection  by  drawing  off  the  urine,  found 
that  his  catheter  had,  with  no  great  lorce,  been  driven  through 
the  membranous  part  ot  the  urethra,  into  the  cellular  substance 
of  the  rectum,  and  thence  into  the  bladder,  through  the  sub- 
stance of  the  prostate  gland;  and  he  naturally  and  justly  infers, 
that  had  the  same  force  been  used  in  the  living  body,  the  vio- 
lence would  not  have  been  fatal,  the  relief  would  have  been 
perfect.  The  celebrated  Dr.  Hunter  bring  occupied  along 
with  a  surgeon,  in  trying  to  introduce  the  catheter,  was  entire- 
ly foiled,  and  the  surgeon  had  gone  home  for  a  trocar  to  punc- 
ture the  bladder;  but  the  doctor  meanwhile  trvingthe  catheter, 
and  using  perhaps  unjustifiable  force,  it  started  suddenlv  into 
the  bladder  :  the  patient  was  lor  the  time  relieved,  but  the  ab- 
domen being  inflamed,  he  died  on  the  thiru  dav  ;  and  it  was 
plain,  upon  dissection,  th  it  the  catheter  had  burst  into  the  blad- 
der, through  the  substance  of  the  gland.  Dr.  Hunter  affects 
to  say,  that  this  was  his  design :  but  since  the  surgeon  was  ac- 
tually  gone  for  the  trocar,  we  have  reason  to  believe  that  the 
doctor  did  not  d<  sign  to  perform  so  important  an  operation,  so 
unprecedented,  and  so  adventurous,  in  the  absence  of  the  surgeon, 
but  gave  a  post  facto  reason  for  what  happened  merely  by 
chance,  by  what  might  have  been  named,  in  a  less  eminent  per- 
son, imprudence  and  rashness. 

Dease,  a  man  intrepid  and  fearless,  and  who  had  not  (to  a 
surgeon  perhaps  it  is  no  reproach)  all  the  delicacv  and  gentle- 
ness of  nature,  which  were  so  justly  admired  in  Dr.  Hunter, 
and  which,  in  his  own  peculiar  di  partment,  had  so  conspicu- 
ous an  influence  on  his  practice,  was  in  the  habit  (and  Icanassure 
the  profession  of  this  curious  fact)  of  driving  his  catheter  right 
onwards  into  the  bladder,  when  at  any  time,  gentle  means  and 
art,  or  cunning,  failed:  he  allowed  no  degree  of  difficulty  to 
frighten  him  from  his  purpose  :  he  assured  me  of  his  success  : 
and  upon  leaving  me,  presented  me,  as  a  token  of  remmibrance, 
with  two  flexible  catheters  of  uncommon  size,  bent  at  the  heel, 
into  a    verv  acute   angle,  and  furnished  with  very  strong  iron 

2H 


242  Of  Puncturing  the  Bladder. 

wires,  assuring  me  that  he  had  often  used  them  thus  success- 
fully, and  soliciting  me  to  make  that  bold  use  of  them,  which, 
thank  God,  I  have  never  had  occasion  to  think  of.  I  would 
not  willingly  acquaint  a  tyro  in  surgery,  with  an  expedient  so 
full  of  danger  ;  if  the  catheter,  ever  is  to  be  forced  thus,  let  it 
be  done  by  a  man  of  judgment  and  skill,  one  who  has  experi- 
ence to  distinguish,  when  it  is  allowable  to  have  recourse  to 
such  an  expedient,  and  who  has  so  much  address  as  to  be  in 
no  danger  of  using  force,  merely  by  being  foiled  for  want  of  art. 
Whether  it  is  from  conversation  or  books,  that  I  have  some  re- 
collection of  a  catheter,  with  a  concealed  canula,  I  do  not  dis- 
tinctly remember.  But  if  so  rash  a  thing  has  been  done,  I  pro- 
test against  it,  "  as  a  sword  put  into  the  hands  of  a  fool/'  Such 
an  instrument  (a  trocar  pointed  catheter)  would  soon  be  in  the 
hands  of  every  young  man,  and  would  prove,  in  surgery,  what 
the  crotchet  is  in  midwifery,  a  merciless  resource:  incases  real- 
ly simple  it  would  be  used,  by  ^oung  surgeons,  with  little  dis- 
cretion. The  catheter  is,  I  am  persuaded,  sufficient,  if  skil- 
fully used,  to  make  its  way  through  almost  any  obstacle. 

The  operation  of  paracentesis  vesicas  is  one  which  the  sur- 
geon must  perfectly  understand,  since  the  occasions  are  sudden 
and  imperious  ;  and  while  he  is  balancing  amidst  imaginary 
difficulties,  or  comparing  a  variety  of  expedients,  (none  ol  them 
without  danger)  his  patient  may  be  lost.  It  is  an  operation 
which  it  is  most  important  to  scheme  and  study,  for  various  ex- 
pedients may  suit  the  circumstances  of  particular  cases.  Of  all 
the  operations  which  I  have  reviewed,  any  one  must  seem  pre- 
ferable to  that  in  common  use  ;  and  that  perhaps  is  best  which 
the  surgeon  can  best  perform. 


(     243     ) 


DISCOURSE  XVI. 


PRELIMINARY  DISCOURSE  ON  THE  ANATOMY 

OF   THE  CRANIUM,    AND  THE  RULES  OF 

PRACTICE  DEDUCED  FROM  IT. 


SECTION    I. 

Introductory  Observations. 

IN  injuries  of  the  head,  the  chief  object  of  your  studies  must  be 
to  learn  the  signs  and  causes  of  danger,  and  tojudge  widely  of  the 
motives  which  should  induce  you  to  operate.  For  in  the  ope- 
ration of  trt- paning,  as  far  as  the  operator  is  concerned,  there  is 
nothing  formidable,  nor  any  thing  which  the  most  unskilful  can- 
not easily,  I  fear  too  easily,  perform. 

But  such  is  the  uncertainty  of  these  signs :  so  often  does  our 
patient  fall  suddenly  into  slight  paralysis,  and  faints  and  expires 
while  we  apprehend  no  harm  ;  so  oiten  does  he  revive  from 
that  stupor  which  seems  to  arise  from  extravasated  blood  op- 
pressing the  brain ;  that  the  diligent  investigation  of  the  true 
signs  of  danger,  of  the  causes  of  oppression,  or  ulceration  of 
the  brain,  (a  severe  and  complicated  study)  should  be  the  chief 
occupation  of  the  surgeon.  But  it  has  not  been  so  ;  operations 
have  been  more  studied  than  the  means  of  avoiding  them. 

Those  who,  on  the  revival  of  learning,  assumed  the  weary 
task  of  explaining  the  first  writers  on  medicine,  were  not  men 
of  practical  skill,  but  philologists,  commentators,  men  of  mere 
learning  ;  and  they  commented  best,  most  learnedly,  and  in- 
deed most  suitably  to  the  text,  who  shewed  themselves  most 
ingenious  in  multiplying  the  distinctions  of  fractures  ;  as  those 
were  thought  to  operate  best,  who  found  means  of  applying  the 
greatest  number  of  trepans  to  one  scull.  But  of  all  the  lessons 
of  the  old  school,  the  one  most  dangerous  to  the  young  sur- 
geon is  that  which  teaches  how  to  distinguish  fissures  from  su- 
tures ;  for  the  rules  for  distinguishing  fissures  clearly  imply, 


244  Of  the  Anatomy  of  the  Cranium. 

that  wherever  siuh  fissure  is  proved  to  exist,  it  is  allowable,  it 
is  necessary  to  tit  pan  the  patient;  and  the  net  a  fracture  oi  the 

scull,  and  the  necessity  ol  ticpaning  the  injured  part,  are  so 
inseparably  connected  in  the  suigeon's  mind,  as  to  lorm  the 
most  essential  rule  in  his  practice. 

In  surgical  s\  stems,  I  do  not  know  any  two  arrangements 
more  irrational,  or  m<  r>  exceptionable,  than  these  two  :  First, 
That  in  treating  of  amputation,  die  aubj<  ct  is  always  opened 
with  a  dissertation  on  gangrene,  as  if  the  lear  of  gangrene,  or 
its  actual  existence,  were  the  sole  motive,  or  at  least  the  most 
frequtnt,  lor  amputating  a  limb.  Secondly,  That  in  explain- 
ing the  operation  ol  trepan,  the  subject  is  invariably  introduced 
with  remarks  on  the  sutures,  the  cancelli,  the  variable  thickness 
of  the  cranial  bones,  and  the  many  scholastic  distinctions  of  ca- 
pillary fissure,  fractures,  depressions,  and  depressed  fractures 
of  the  sculi,  as  if  such  fracture  or  fissure  were  the  sole  motive, 
or  the  most  prevailing  one,  for  applying  the  trepan.  This  is  not 
the  meaning  of  our  operation  ;  we  often  perforate  with  the  tre- 
pan, to  give  vent  to  the  purulent  matter,  often  to  give  vent  to 
extravasated  blood,  sometimes  on  account  of  a  depression  of 
the  bone,  sometim  s  to  cut  away  sharp  points  which  may  hurt 
the  brain  or  membranes,  or  to  take  away  balls  or  foreign  bo- 
dies nitched  into  the  subMance  of  the  bone,  but  never  on  ac- 
count of  mere  fracture  of  the  scull.* 

First,  You  are  desired  to  remark  the  constitution  of  these 
flat  bones,  u  that  they  are  composed  of  two  tables  or  plates  of 
solid  bone,  with  intermediate  cancelli,  (or  cellular  substance, 
such  as  is  natural  to  bone,  full  of  blood  vessels)  which  bleed 
when  with  your  trepan  you  have  sawed  through  the  outer  table, 
occasioning  at  the  same  time  a  change  of  sound."  This,  though 
occasionally  modified,  you  are  taught  to  regard  as  a  rule  of 
practice;  and,  to  every  elementary  book,  you  find  it  to  be  a 
most  important  subject  of  debate,  whether,  in  perforating  the 
scull,  you  should  use  thv  trephine,  which  saws  rapidly,  or  the 
trepan,  which,  from  making  onl\  half  circles,  cuts  more  slowly; 
or,  whether  you  should  first  use  the  trephine,  till  you  have  cut 
down  to  the  cancelli,  and  finish  the  more  delicate  part,  the  saw- 
ing off  the  inner  table  with  the  trepan,  Nev^r,  perhaps,  was 
any  remark  more  unfortunate  than  this,  which  refers  the  sur- 
geon to  the  bleeding  and  the  change  of  sound,  as  signs  of  hav- 
ing cut  through  the  outer  table,  and  teaches  him  to  be  proud  of 
sawing  rapidly.  Of  all  operations,  this  is  the  one  where  pre- 
cipitant^ and  hurry  have  the  fewest  apologies,  since  the  patient 
usually  lies  insensible,  since  the  sawing  of  a  bone  occasions  no 

*  All  the  dire&ions  therefore,  which  the  older  phvficians,  from  Hippocrates 
downwards,  have  given  for  the  dikovery  of  fradures  and  fiflures,  are  now  ufe- 
lefs.     S. 


Of  the  Anatomy  of  the  Cranium.  245 

pain,  since  the  trepan  is  an  operation  where  haste  may  occasion 
the  must  dismal  const  quern,  es,  from  wounding  the  dura  mater, 
which,  when  Left  uninjured,  supports  the  brain  (after  the  re- 
moving of  a  piece  of  the  cranium)  like  a  second  scull. 

Secondly,  But  this  first  suggestion  is  inconsistent  with  a  rule 
much  more  worthy  ot  notice;  viz.  "that  in  all  circumstances 
the  surg-.on  should  saw  cautiously,  on  account  ot  the  incalcula- 
ble irregularities  in  the  thickness  in  the  cranium,  which  is  uni- 
versally thin  in  boys  and  very  aged  people,  and  is,  during  all 
the  middle  stages  of  lile,  extremely  irregular,  generally  thick, 
but  at  certain  points  extremely  thin,  or  excavated  by  the  deep 
impressions  of  tortuous  veins."  I  approve  of  sawing  the  cranium, 
in  all  circumstances,  with  prudence  and  deliberation  ;  but  yet  I 
discover,  in  all  these  rules,  intrinsic  marks  of  their  having  been 
invented  by  mere  speculators  in  surgery,  not  by  surgeons ;  for 
in  truth  we  almost  never  operate  in  a  mere  fracture  of  the  scull ; 
we  almost  never  operate  where  the  bone  is  sound,  and  the  dura 
mater  closely  attached  to  the  bone  ;  even  in  cases  of  extensive 
fracture,  we  rarely  operate  except  on  account  of  some  affection 
of  the  brain. 

Thirdly,  The  artery  of  the  dura  mater  is  described  with  a 
particular  reference  to  the  operation  ol  trepan.  "  As  an  arury 
of  considerable  size,  the  chiet  arten  oi  the  dura  mater,  run- 
ning along  the  inner  surface  ot  the  parietal  bone,  marking  the 
anterior  corner  of  the  bone  with  its  trunk,  and  the  upper  part 
with  the  impression  of  its  branches,  and  making  a  groove  so 
deep,  that  the  bone  cannot  be  entirely  cut  through  b\  the  trepan, 
without  the  artery  being  divided.  For  these  reasons  it  is  ad- 
vised, that  the  surgeon  should  avoid  the  whole  tract  ol  this  ar- 
tery, and  especially  that  he  should  not  trepan  the  lowtr  corner 
of  the  parietal  bone"  That  the  surgeon  should,  except  in  ca- 
ses of  the  most  absolute  necessity,  avoid  even  the  shadow  of 
danger,  is  a  precept  from  which  I  will  not  allow  myself  to  dis- 
sent. But  in  this,  as  in  all  these  notable  observations  on  the 
cranium,  there  are  strong  intrinsic  marks  of  the  reflection  com- 
ing from  one  little  acquainted  with  practical  surgery  ;  for  in  all 
circumstances,  and  on  all  points  ot  the  scull,  have  I  seen  the 
trepan  applied  without  much  skill,  or  any  thing  ol  this  fore- 
sight, but  never  have  I  seen  or  heard  of  a  hsemorrhagy  from 
the  artery  of  the  dura  mater*. 

*  Mr.  A.  Cooper  mentions  in  his  Lectures,  an  inilance  in  which  this  artery  was 
divided  by  the  trepan,  the  hitmorrhugy  was  at  fiift  confiderable,  but  eafily  fup- 
prefled  by  a  piece  of  lint  prefled  upon  ir  tor  a  fhort  time.  That  this  artery  muft 
be  inevitably  wounded  in  iemovinj<  the  anterior  and  inferior  corner  of  the  parietal 
bore  in  a  pieat  majority  of  cales,  is  molt  certain,  of  which  any  perfon  will  be 
fktitfied  upon  examination.     S. 


246  Of  the  Anatomy  of  the  Cranium. 

Fourthly  ^  You  are  warned  of  the  danger  of  wounding  another 
important  vesstrl, — the  Longitudinal  Sinus.  You  are  told,  "  that 
the  longitudinal  sinus  is  the  greatest  vein  of  the  brain,  named 
longitudinal  from  its  running  along  the  whole  length  of  the  scull, 
and  changing  its  name  at  the  occiput,  where  it  forks  into  the 
branches  which  terminate  in  the  great  jugular  veins,  and  are 
called  the  lateral  sinuses  ;"  and  it  was  set  down  as  a  very  abso- 
lute rule,  M  that  the  scull  should  never  be  trepaned  in  the  line 
of  the  sagittal  suture,  under  which  this  sinus  lies." — You  are 
told  that  such  a  wound  is  fatal. 

This  is  none  of  the  surgeon's  rules,  who,  if  he  had  at  all 
mentioned  the  longitudinal  sinus,  would  probably  have  observed 
how  sluggishly  the  blood  moves  along  in  the  great  sinus ;  that 
it  is  more  properly  a  reservoir  than  a  vein ;  that  there  sure- 
ly could  be  little  danger  in  wounding  it ;  that  often  when  we 
find  it  necessary  to  operate  in  the  direct  course  of  this  canal,  we 
feel  it  turgid  under  the  finger,  that  in  such  a  case  the  temptation 
is  too  strong,  not  to  be  yielded  to,  of  striking  the  bleeding  lan- 
cet into  it,  with  the  hopes  of  relieving  the  patient  from  the 
lethargv  in  which  he  lies.  Warner  and  Pott  have  both  seen  the 
longitudinal  sinus  punctured  by  fragments  of  bone,  and  the  blood 
flowing  from  it  profusely,  which  was  yet  more  easily  stopped 
than  that  flowing  from  a  vein,  merely  by  applying  to  it  a  piece 
of  dry  lint.  Pott  and  Warner  have  both,  without  scruple, 
opened  the  sinus  with  a  lancet,  and  bled  the  patient  from  it.*. 

Calisen,  the  celebrated  Danish  surgeon,  having  trepaned  a 
sailor  who  was  knocked  down  by  a  block  falling  from  above, 
felt  the  sinus  lying  turgid  under  the  finger,  and  seeing  no  pros- 
pect of  the  oppression  in  which  his  patient  lay  being  relieved, 
bled  him  from  the  sinus  with  as  little  concern  as  he  would  have 
done  from  the  jugular. 

Fifthly^  I  am  now  to  speak  of  a  rule  more  purely  hypothe- 
tical than  any  I  have  yet  commented  upon.  The  dura  mater 
was  supposed  by  the  ancients  to  pass  through  the  scull  by  the 
indentations  of  the  sutures,  not  merely  to  connect  itself  with  the 
pericranium,  but  to  form  that  membrane,  and  from  thence  was 
supposed  to  be  derived  all  the  membranes  of  the  body. 

The  name  of  Crassa  Meninx,  or  Dura  Mater,  was  derived 
from  this  imaginary  office  of  forming  all  the  other  membranes, 
and  the  surg<  ons  were  advised  not  to  scrape  the  sutures  with 
the  rugine,  nor  trepan  near  them,  lest  he  should  injure  this 
most  important  connection. 

The  surgeon  is  called  upon  to  remark  the  peculiar  firmness 
with  which  the  dura  mater  adheres  to  the  sutures,  and  coun- 

*  Vide  Warner's  Cafes,  p.  10.     Pott's  Surgical  Works,  vol.  I.  p.  J96r 


■ 


Of  the  Anatomy  of  the  Cranium.  247 

selled  not  to  apply  the  trepan  exactly  upon  a  suture,  when  the 
dura  mater  adheres  so,  but  on  each  side  of  the  suture,  so  as 
to  be  thus  sure  of  finding  the  extravasation.  But  I  no  more 
find  this  adhesion  capable  ol  limiting  extravasation,  than  the 
sutures  capable  of  stopping  fractures.  1  find  the  extravasation 
always  extending  beyond  the  place  ot  the  sutures,  and  covering 
very  generally  one  entire  hemisphere  ot  the  brain.  I  never  saw 
any  occasion  tor  applying  the  trepan,  first  on  the  one  side,  then 
on  the  other  side  of  the  suture,  though  much  has  been  written 
on  this  subject.  I  find  in  no  book  a  proof  of  extravaNation  hav- 
ing been  limited  and  interrupted  by  intervention  of  a  suture,  nor 
one  case  unequivocally  stated,  where  the  surgeon,  having 
applied  his  trepan  on  one  side  of  a  suture,  was  obliged  to  repeat 
his  operation  on  the  other  side. 

Sixthly,  In  describing   the  frontal  bone,  its  internal  spine 
or  ridge  running  longitudinally  along  its  inner  surface,  is  point- 
ed out  as  particularly   interesting  to  the  surgeon,  as  being  an 
absolute  bar  to  the  perforating  of  that  part  of  the  bone.     The 
observation  seems  important,  the  difficulty  seems  demonstrable; 
but  this,  though  it  be  a  difficulty  which  must  naturally  present 
itself  to  the  imagination  of  the  speculative  anatomist,  is  one 
which  can  have  but  a  slight  influence  over  the  resolution  of  the 
practical  surgeon.      He  recollects,  that  in  most  of  his  operations, 
even  upon   the  most  level  and  equable  parts  of  the  cranium,  he 
seldom  dares  to  cut  both  tables  of  the  cranium  entirely  through, 
but  leaves  part  of  the  circle  uncut,  and  begins  with  his  elevator 
to  poise  out  the  sawed  piece  of  bone,  before  it  is  entirely  insu- 
lated ;  the   part  that  is  uncut  usually  breaks  and  splinters  with 
an  audible  noise,  and  he  smooths  the  ragged  edges  of  the  trepan 
circle,  with  the  instrument  named  Lenticular.     Though  a  well- 
instructed  surgeon  will  not  fail  to  recollect  this  internal  ridge  of 
the  os  frontis,  he  will  nevertheless  pertorate  here  when  the  ope- 
ration is  required  at  this  point,  with  this  sole  precaution,  that 
he  will  saw   more  circumspectly,  will  cut  through  all  that  he 
safely  can  of  the  circle,  burst  up  the  rest,  and  smooth  the  rag- 
ged edges  of  the  hole.     It  is  only  in  one  single  point,  at  the 
very  root  of  the  nose,  at  a  point  considerably  lower  than  we 
ever  need  to  perforate,  it  is  only  in  the  very  middle  betwixt  the 
brows,  and  in  a  space  no  bigger  than  one  crown  of  the  trepan 
will  cover,  that  this  spine  can  at  all  prove  an  interruption.     I 
know  no  mischance,  by  which  the  most  ignorant  person  could 
be  induced  to  apply  the  trepan  so  low,  and  believe  that  there  is 
more  danger  of  a  thoughtless  operator  doing  harm  when  tre- 
paning  upon  the  ridges  of  the  occipital  bone  ;  but  in  neither 
the  one  place  or  the  other  is  the  trepan  required  ;  of  an  hun- 
dred cases  in  which  this  operation  is  required,  the  instrument 


248  Of  the  Anatomy  of  the  Cranium, 

is  placed  in  ninety-nine  cases  upon  the  upper  parts  of  the  scull, 
upon  the  parietal  or  frontal  bones. 

The  rules  which  I  deprecate,  often  incline  the  young  surgeon 
to  deviate  from  the  plain  way  of  common  sense,  and,  by  avoid- 
ing imaginary,  he  runs  into  real  dangers.     To  understand  the 
case  1  am  now  going  to  relate,  you  must  assent  to  one  principle, 
which  1  shall  afterwards  prove  in  the  most  unequivocal  terms  ; 
and  it  is  this  :  "  That  mere  depression  of  the  scull,  which  was 
once  believed  to  be  the  most  perilous  of  all  accidents,  has  really 
but  a  very  slight  effect  in  compressing  the  brain."*    The  line  of 
a  depressed  bone  deviates  but  in  a  very  slight  degree  from  the 
natural  convexitv  of  the  scull  ;  the  dt  pression,  as  such,  produ- 
ces no  compression,  for  the  patient  walks  about  unaffected,  or 
but  very  slightly  ;  and  if  he  falls  into  a  dangerous  state,  it  is 
indicated  by  tremblings  of  the  hands  and  knees,  a  sort  of  imbe- 
cility, slight  shiverings  and  nausea,  which  are  signs,  not  of  com- 
pression, but  ulceration  of  the  brain  or  its  membranes.     The 
bone  itself  is  sometimes  deadened  by  the  blow,  or  its  spiculae 
and  fractured  edges  stick  in  the  membranes,  and  occasion  sup- 
puration ;  while  the  integuments  continue  entire  over  a  Iractu- 
red  bone,  the  interstices  often  are  filled  with  extravasated  blood 
and  gluten,  and  soon  become  vascular,  so   that  the   bone  re- 
unites, as  in  the  fracture  of  a  limb,  and  the  brain  and  its  mem- 
branes remain  sound  ;  but  if  the  integuments  be  much  injured, 
and  the  depressed  and  fractured  bone  exposed,  ulceration  is  apt 
to  ensue. 

M  W L ,  a  chimney  sweep,  fell  from  the  third 

story  of  a  house,  upon  a  street  paved  with  very  coarse  round 
stones  ;  though  he  had  sustained  a  very  dreadful  fracture  of 
the  scull,  he  was  very  little  affected,  and  not  brought  into  our 
hospital  till  eight  days  after  the  fall.  The  clerk  or  surgeon,  far 
from  expressing  an  alarm  either  at  the  nature  of  the  accident,  or 
the  peculiarity  of  the  svmptoms,  described  the  case  thus  in  the 
books  :  u  He  has,  on  the  lower  part  of  the  frontal  bone,  a 
fracture  in  the  form  of  the  letter  V,  about  an  inch  in  length,  and 
with  a  spot  of  the  cranium,  which  you  could  cover  with  the 
point  of  \our  finger,  bare,  but  without  any  mark  of  depres- 
sion.'' Bv  marks  of  depression  was  meant,  perhaps,  "  signs  of 
oppressed  brain :"  for,  though  he  had  no  such  signs,  the  de- 
pression was  gr<  at,  and  was  easilv  distinguished  bv  the  finger 
or  the  probe.  Wh~n  I  first  saw  this  man,  he  was  sitting  up  in 
bed,  submitting  to  the  operations  of  the  dresser,  talking  ration- 
ally, and  apparently  little  injured  ;  and  I  was  told  that  I  might, 

"  That  mere  depreflion  of  the  fcull,  and  that  to  no  great  degree,  will  frequently 
produce  ah  the  fymptora*  of  opprt  fitd  brain,  is  clearly  proved  by  the  relief  which 
'^nfaes  immediately  the  depreffed  bone  is  elevated  or  removed.     S. 


Of  the  Anatomy  of  the  Cranium.  :i4>9 

if  I  pleased,    feel  a  fracture  pretty  distinctly,   but  without  de- 
pression, and  that  the  patient  was  in  no  danger. 

I  formed  a  different  conclusion  from  every  circumstance  of 
this  case.  The  height  from  which  the  patient  fell  was  very  griat; 
he  had  fallen  perpend icularly-upon  the  forehead,  else  it  could  not 
have  been  fractured,  and  he  had  not  broken,  nor  even  sprained, 
a  wrist  oranclt ,  so  that  there  was  no  intermediate  shock  to  break 
his  fall.  He  was  indeed  sitting  on  tht  side  ol  his  bed,  hut  ex- 
tremely meagre,  sickly,  pale,  languid,  and  dejected  ;  his  eve 
was  sunk,  his  cheek  hollow,  and  his  lace  somewhat  distorted 
with  spasmodic  twitches.  Upon  opening  the  lip  ol  this  trian- 
gular wound,  which  was  now  suppurating,  and  puffy,  I  lound 
that  the  fracture  seated  exactly  in  the  middle  of  the  forehead, 
was  very  wide,  and  that  the  bone  at  the  lower  part  of  the  frac- 
ture, and  immediate^  over  the  eye-brow,  v. as  much  depressed; 
and,  worse  than  all,  [  found  the  bone  so  complt  tel\  discolour* 
ed,  that  though  the  depression  did  not  affect  the  brain,  the  ca- 
ries, I  was  sure,  would,  in  process  of  time,  aff<  ct  its  mem- 
branes, and  cause  suppuration.  That  the  fatal  symptoms  were 
begun,  I  was  convinced,  b\  a  more  deliberate  examination  of 
his  nurse  and  attending  friends  ;  for,  though  he  sat  on  his  bed, 
bore  the  perpendicular  posture,  and  sum  rid  the  operations  of  the 
tlresser;  though  he  answered  p>  rtinently  to  all  our  questions  ; 
his  articulation  was  slo.v,  his  motions  languid  and  listless,  his 
eye  oppressed,  his  breathing  anxious,  and  accompanied  with 
sighing  There  was  a  sort  of  sardonic  grin,  or  distortion  of 
face,  and  a  silliness  or  fatuity  of  look.  Hs  pulse  was  quick 
and  irritable,  his  tongue  parched  ;  he  had  a  hectic  flush  upon 
his  cheek.  Though  he  made  no  complaint,  he  was  sickly,  his 
hands  trembled,  he  vomited  frequently  during  the  night.  He 
was  always  slightlv  delirious  during  the  night,  before  he  was 
thoroughly  roused  ;  and  during  the  daw  he  walked  round  his 
bed,  fumbled  aSout  the  clothes,  seemed  to  wish  to  do  some- 
thing, yet  had  no  purpose.  In  short,  he  was  in  a  state  of  in- 
describable disorder,  never  soundly  asleep,  nor  entirely  awake  ; 
and,  though  his  sickly  condition  conveyed  no  intimation  of  ap- 
proaching danger  to  his  ignorant  friends,  it  could  not  but  be 
observed  bv  his  medical  attendants;  for  these  are  the  signs, 
slight  as  thev  appear,  which  announce  suppuration  within  the 
cranium,  and  approaching  palsy. 

A  consultation  having  advised  that  the  patient  should  be 
trepaned,  the  operation  was  performed  with  su<  h  circumstan- 
ces of  misconduct,  as  I  think  very  impressive  and  instructive. 

2  I 


250  Of  the  Anatomy  of  the  Cranium. 

There  was  a  large  transverse  fracture  across  the  lower  part  of 
the  frontal  bone,  with  one  limb  extending  into  the  orbit.  The 
lower  part  of  the  bone  above  the  frontal  sinus  was  depressed  the 
full  thickness  of  the  bone,  and  the  depressed  portion  of  the  bone 
was  plainly  carious,  black,  and  dead.  Unhappily  the  rules  of 
surgery,  which  the  operator  but  too  well  remembered,  and  ap- 
plied too  accurately,  were  in  every  thing  opposite  to  the  dictates 
of  good  sense.  The  rule  says,  "  apply  your  trepan  upon  the 
sound  bone,  which  can  best  bear  it,  that  you  may  be  able  to 
press  your  levator  under  the  depressed  bone  through  the  trepan- 
hole."  But  common  sense  directs  no  man  to  cut  away  a  sound 
and  living  portion  of  the  cranium,  to  save  by  elevation  a  part 
which  is  depressed,  and  perhaps  dead.  The  rules  of  surgery 
say,  "  You  shall  not  trepan  on  or  near  the  frontal  sinus  ;"  while 
common  sense  requires  the  surgeon  to  perforate  wherever  any 
cause  of  danger  exists.  The  rules  of  surgery  would  impress 
us  with  the  belief,  that  "  of  all  the  accidents  of  fracture,  depres- 
sion of  the  skull  is  the  most  fatal  cause  of  compressed  brain,  and 
the  one  which  most  immediately  requires  the  operation  of  tre- 
pan ;"  while  this  very  case,  combined  with  a  thousand  colla- 
teral proofs,  shows  how  slightly  the  greatest  depression  of  the 
cranium  affects  the  functions  of  the  brain,  for  fifteen  days  had 
elapsed  before  it  was  distinctly  known  that  the  bone  was  depres- 
sed, or  the  man  in  danger. 

Though  the  depression  of  the  scull  was,  in  this  case,  the  cir- 
cumstance which  should  chiefly  have  attracted  the  attention  of 
a  tyro,  thinking  only  about  the  anatomy  of  the  scull,  and  ima- 
gining nothing  more  correct  or  absolute  than  these  mechanical 
rules  ;  the  carious  or  dead  part  ot  the  bone  affecting  the  dura 
mater  as  a  loreign  body,  would  alone  have  appeared  important 
to  one  who  reasoned  on  the  affections  of  the  brain,  and  knew 
them  by  their  signs.  The  one  would  have  thought  only  of  ele- 
vating the  depressed  portion  of  bone,  the  other  of  cutting  away 
whatever  was  dead.  The  one  would  have  applied  the  trepan 
upon  the  sound  bone,  the  other  would  have  applied  it  upon  the 
injured  part. 

Resolved  to  perforate  as  far  as  possible  from  this  formidable 
sinus,  the  frontal  sinus,  the  operator,  instead  of  elongating  the 
triangular  wound  of  the  integuments  downwards,  prolonged  it 
by  incisions  upwards,  and  applied  the  crown  of  his  trepan  upon 
the  sound  and  undepressed  bone  above  the  fracture.  The  os 
frontis  was  extremely  thick,  like  that  of  a  rachitic  person  ;  in 
avoiding  the  frontal  sinus,  he  encountered  the  frontal  spine, 
and  was,  though  it  may  seem  incredible,  fully  an  hour  in  ac- 
complishing the  perforation,  the  patient  all  the  while  crying  out, 


Oftrepaning  the  Frontal  Sinus.  251 

struggling,  and  taunting  him  with  expressions  which  I  thought 
he  very  well  deserved.  But,  alter  having  sacrificed  this  sound 
part  of  the  scull  in  favour  of  a  part  carious  and  irrecoverable, 
he  found  the  depressed  portion  not  only  well  able  to  bear  the 
working  of  the  trepan,  but  so  exceedingly  firm,  that  no  lorce  of 
levers  could  enable  him  to  raise  it.  The  optrator,  conscious 
that  he  had  by  this  perforation  clone  nothing  effectual  for  the 
relief  of  a  patient  who  had  endured  so  much,  was  now  willing, 
after  an  intermediate  consultation,  to  attempt  what  should  have 
been  done  at  first.  The  incision  of  the  integuments  was  car- 
ried downwards  through  the  eye- brow,  to  the  root  of  the  nose  ; 
the  whole  extent  of  the  depression,  and  of  the  deadened  por- 
tion of  the  bone,  was  now  displayed.  The  fracture  was  seen 
running  down  into  the  orbit ;  the  operator  would  have  now  ap- 
plied his  trepan  upon  the  depressed  portion,  which  should  have 
been  first  cut  away  ;  but,  alter  operations  and  consultations  last- 
ing an  hour  and  a  half,  the  patient,  exhausted  by  his  cries,  re- 
sistance, and  loss  of  blood,  the  manifest  inhumanity,  too,  of  con- 
tinuing such  unavailing  cruelties,  induced  the  surgeon  to  com- 
mit his  patient  to  bed,  where  his  rest  was  long  and  sound. 
What  he  suffered  afterwards,  I  had  not  the  courage  to  inquire, 
but  he  died. 


SECTION    II. 


Oftrepaning  the  Frontal  Sinus. 

The  alarm  about  wounds  of  the  frontal  sinus  has  been  uni- 
versal ;  the  injunctions  not  to  approach  it  with  the  trepan  have 
been  transcribed  from  book  to  book,  in  the  same  unvar)ing  lan- 
guage. 

But  never  having  been  accustomed  to  indulge  these  irrational 
fears,  I  trepaned  this  sinus*  in  a  case  ol  general  convulsion, 
singular  in  all  its  circumstances,  and  not  uninstructive,  but  es- 
pecially in  this  respect,  that  it  was  plainly  connected  with  a  dis- 
ease of  the  (rontal  sinus. 

"A  very  tall,  well-made,  and  handsome  lad,  about  twenty- 
four  years  of  age,  a  house-carpenter  in  Appleby,  while  assisting 
his  tellow-workmen  in  laying  a  heavy  beam  upon  the  frame  of 
a  saw-pit,  slipped  a  foot,  and  falling   forwards,  had  his  head 

*  Although  the  frontal  fin  us  may  undoubtedly  be  trepaned,  it  is  certainly 
rarely,  if  ever,  ncceffary  to  do  it,  foas  to  expofe  the  brain,  which  is  the  reafaa 
why  the  furgeon  is  directed  to  avoid  it.  As  to  merely  opening  the  finus  it  fell", 
there  can  be  neither  difficulty  nor  dangi  r  in  rhc  operation.     3. 


252  Oftvpaning  the  Frontal  Sinus. 

immovably  wedged  betwixt  the  beam  whit  h  they  were  lifting, 
and  that  whan  had  just  been  laid  upon  the  frame  ;  and  so  hca- 
vj  was  this  log,  that  his  companion/  w»  re  ol.liged  to  take  tluir 
hand-spikes  and  pois<  it  up  Hi  ernd  out  uuring  the  time  his 
head  was  wedged  between  thi  logs,  and  when  released  was  able 
to  rise;  though  g'dd\,  he  was  not  insensible  ;  nor  did  the  biood 
burst  from  his  nose  and  ears,  as  m.ght  have  been  expected  al- 
ter such  an  injury. 

"  1  hough  his  head  suffered  this  pressure  on  the  sides,  being 
compressed  from  temple  to  temple,  there  is  every  reason  to  be- 
lieve that  the  loreheau  had  suffered,  and  the  frontal  sinus  be<  n 
injured  ;  tor  he  walked  home  under  the  agony  ot  an  acute  head- 
aeh  which  sown,  however,  subsided  into  a  heavy,  dull,  and 
continued  pain,  aggravated  at  times,  but  never  entirely  absent. 
His  head  was  contused  ;  he  gradually  lost  his  hearing,  and  by 
t'ne  third  week  irom  the  time  ol  the  injur},  was  entirely  deaf: 
he  returned  to  work,  but  his  headach,  giudincss,  and  deafness, 
were  unremitting,  and  he  had  occasion  to  remark,  that  M  he 
never,  from  the  moment  of  that  bruise,  had  a  good  head  lor 
standing  or  working  in  difficult  places." 

14  The  sudden  manner  in  which  he  regained  his  hearing,  and 
the  proiuse  flow  ot  matter  from  the  ears  and  nc  strils,  which 
opened  the  passages,  are  very  remarkable.  It  happened  about 
a  fortnight  atter  losing  his  hearing,  that  while  he  was  working 
in  the  fields,  upon  blowing  his  nose,  there  rushed  out  trom  one 
ear  a  great  quantity  oi  matter,  with  a  painlul  noise.  He  tell 
down  by  the  wad  in  a  sort  oi  fit,  lay  lor  sonic  time  insensible, 
and  when  his  senses  returned,  he  was  as  much  surprised  at  hear- 
ing the  barking  of  dogs,  and  the  voices  ot  the  people  in  the 
neighbouring  village,  as  it  he  had  been  bom  deal.  He  now 
found  that  matter  was  flowing  from  the  nostrils,  as  well  as  irom 
the  tar,  with  a  smell  so  offensive,  tnat  at  first  he  imagined  that 
his  hat  in  his  fall  must  have  lain  in  some  ioul  place.  He  smelt 
his  hat  first,  and  looked  to  it,  but  lound  it  not  soiled,  nor  loul, 
and  upon  blowing  his  nose,  there  run  out  into  his  handkerchief 
a  prolusion  ot  foul  and  very  tetid  matter,  mixed  with  blood. 

M  When  he  had  tull\  recovered  his  senses,  he  lound  that  the 
discharge  of  blood  and  matter  from  the  nose  was  accompanied 
wuh  agonizsng  pains  in  his  head  ;  he  retired  to  the  shelter  ol  an 
unfinished  house,  where  his  companions  had  been  working, 
and  threw  himself  down  on  a  b  d-trame,  and  lav  there  alone  till 
evening,  with  his  head  hanging  over  the  bed-frame,  a  black,  fe- 
tid, and  blood)  matter  distilling  profuseb  from  his  right  nos- 
tril, while  an  acute  and  confused  Dain  ran  through  his  forehead. 
He  got  up,  after  some  hours,  and  walked  to  his  lathe  r's  house, 
about  a  mile  distant,  in  great  pain  ana  contusion  ol  head. 


Of  trepaning  the  Frontal  Sinus.  253 

"  From  this  time  the  pain  in  his  forehead  was  unremitting 
and  severe,  and  when  heated  at  work,  it  was  particularly  vio- 
lent.* This  pain,  at  the  root  of  the  ion  head,  was  aggravated 
at  times  to  violent  paroxysms  ;  it  affected  the  eye,  puffed  up 
the  eye-lid,  swelled  the  whole  side  ol  the  fact  ano  forehead* 
The  discharge  from  the  nose  continued  vcr)  profuse,  and  this 
local  disease,  accompanied  with  general  headachs,  aflhctid  lum 
for  live  )  ears,  and  a  permanent  bony  swelling,  mark  d  by  a  ve- 
ry conspicuous  protuberance  of  the  right  eye-i>row,  at  the  place 
of  the  frontal  sinus,  was  formed. 

M  But  his  complaint  underwent  a  sad  revolution  in  conse- 
quence of  a  second  lall,  which  happeni  d  thus  :  Alter  mowing 
hay  in  weather  which  was  oppressive!)  hot,  he  retired  with  the 
other  labourers  at  mid-da\,  to  rest  in  the  hay-lolt;  being  over- 
come with  labour,  and  having  fallen  into  a  perturbed  sleep,  he 
by  successive  restless  motions  got  so  near  the  edge  oi  the  loft, 
that  he  at  last  shpt  over.  One  ol  his  iellow  labourers  chanced 
at  that  moment  to  observe  him  sliding,  and  ran  to  catch  him  by 
the  leet,  but  too  late,  for  he  fell  lrom  the  loft  headlong,  upon 
a  rugged  pavement  of  big  round  stones,  and  alighted  exactly 
upon  that  part  of  the  forehead  which  had  been  long  the  seat  of 
disease  ;  lor  I  find  the  scar  of  the  wound  winch  he  then  received, 
just  over  the  bulging  of  the  tight  lrontal  sinus.  He  lay  insen- 
sible during  a  quarter  of  an  hour,  and  when  he  revived  he  felt 
sick,  faint,  and  languid  ;  and  his  companions  being  gathered 
about  him,  he  waved  his  hand  as  for  room,  and  a  freer  breath- 
ing-space. They  carried  him  into  the  open  air,  where  he  in- 
stantly fell  into  an  epileptic  fit,  which  epilepsy  has  continued 
ever  since. 

"  The  epileptic  paroxysms  returned  frequently,  at  least  every 
night  and  morning,  trom  the  time  of  this  lall.  He  was  weakly, 
almost  paralytic,  walked  only  with  the  help  of  stilts,  and  trailed 
h.s  limbs  along.  In  about  five  weeks  he  had  so  far  recovered, 
as  to  think  himself  strong  enough  for  work,  and  the  paroxvems, 
which  had  at  first  recurred  three  cr  four  times  a-dav,  became 
less  frequent,  Ceased  at  last,  and  were  absent  entirely  for  a 
week.  Thus  encouraged,  he  r<  turned  to  his  daily  labours,  and 
by  the  violence  of  his  labours  the  fits  came  on  again.  He  had 
been  now  six  months  labouring  under  this  disease,  is  reduced, 
weakened,  and  dispirited  ;  is  distorted  with  these  fits  ol  spasm 
or  convulsion  twice  a«dav  at  least,  and  tormented  from  hour  to 
hour  with  severe  threatenings.  Fits  so  peculiar,  and  proceeding 
lrom  so  unusual  a  cause,  1  think  it  right  to  describe  with  par- 
ticular care. 

•  He  recovered,  about  a  fortnight  a.fter  tlii*,  the  hearing  of  his  other  ear,  by  z 
l:ke  difcharge  of  matter,  which  alio  happened  luddenly  upon  blowing  his 


254  Of  trepaning  the  Frontal  Sinus. 

"  The  convulsion  is  distinctly  connected  with  the  disease  of 
the  forehead.  The  approach  of  each  paroxysm  is  announced 
by  pain  of  the  forehead,  with  a  sense  oi  fulness  ;  first  his  jaw 
begins  to  shake  with  a  trembling,  and  convulsive  motion,  and 
the  tongue,  too,  trembles,  and  is  retracted  into  the  mouth. 
This  is  the  warning  or  first  alarm  of  the  approaching  parox- 
ysm, which  somt  times,  as  he  imagines,  he  prevents  by 
clenching  the  jaws,  and  holding  them  firmly.  Being  once  at- 
tacked wfu-n  reading,  he,  in  hopes  of  stopping  the  convulsion, 
thrust  the  book  into  his  mouth,  the  convulsion  increased,  and 
was  as  usual  propagated  along  the  neck,  arm,  and  side  ;  the 
book  was  so  fixed  by  the  convulsion  of  the  jaw,  that  he  had  no 
power  to  withdraw  it,  and  the  suffering  was  so  dreadtul,  that 
he  remembers  having  howled  with  agony. 

"  But  the  convulsion  only  begins  in  the  jaws,  then  trembling 
and  convulsive  motions  run  downwards  along  the  neck  :  his 
head  is  turned  to  the  right  side,  while  his  neck  is  tortured  with 
the  spasm  ;  the  convulsion  descends  from  the  neck  down  the 
arm,  and  to  the  hand,  which  is  clenched  and  contracted,  till  the 
whole  of  the  right  side  is  affected  with  it. 

**  Besides  frequent  threatenings,  and  incessant  fear,  he  has 
three  or  four  regular  paroxysms  during  the  day.  He  is  warned 
of  its  approach,  like  those  who  have  the  aura  epileptica,  by 
slight  distortions  of  the  parts,  and  a  confused  sensation  in  the 
forehead  ;  he  immediately  clings  to  a  bed-post,  a  chest  of  drawers, 
a  door,  or  some  firm  body,  continues  sensible,  and  feels  all  the 
horror  of  its  slow  approach,  and  all  the  pains  of  the  convulsion ; 
and  the  perpetual  fear  of  this  attack  has  given  his  countenance  an 
anxious,  subdued,  and  melancholy  cast.  First  in  orderly  succes- 
sion, comes  the  pain  and  fulness  of  the  forehead,  then  the 
tremblings  of  the  jaw  and  tongue,  then  the  sore  contractions  of 
the  neck,  which  draw  his  head  over  the  right  shoulder,  and  then 
successive  cramps  and  convulsions  of  all  the  right  side  of  the 
body,  till  it  is  bent  down  ;  and  in  this  state  of  agony  he  continues 
four  or  five  minutes,  when  the  muscles  of  the  side,  of  the  arm 
and  of  the  neck  gradually  and  successively  tremble,  and  fall  into 
a  quiescent  state,  and  the  convulsions  of  the  neck  and  arm  having 
remitted,  the  spasm  of  the  jaw,  and  trembling  and  retraction  of 
the  tongue  also  cease,  and  then  he  returns  slowly  to  his  seat.  He 
is  alwa\s  in  great  confusion,  but  never  insensible,  during  the  fits, 
unless  it  be  during  the  night  ;  for  it  would  appear,  that  during 
sleep  he  is  seized  with  fits  more  nearly  approaching  to  the  nature 
of  true  epilepsy.  He  passes  his  faeces  and  urine  involuntarily 
during  the  night.  His  disease  has,  if  not  the  express  form,  at 
least  the  effects  of  epilepsv  ;  for  his  faculties  begin  to  fail,  his 
memory  is  injured,  certain  words  he  is  unable  to  pronounce, 


Of  trepaning  the  Frontal  Sinus.  255 

or  pronounces  them  with  a  painful  and  convulsive  hesitation. 
Although  he  does  not  actually  fall  down,  his  confusion  during 
a  paroxysm  amounts  almost  to  insensibility,  and  each  parox>sm 
is  followed  by  drowsiness  and  a  degree  of  oppression,  so  that 
very  commonly  he  falls  asleep,  his  right  eye  is  turned  obliquily 
inwards,  the  swelling  ol  the  frontal  sinus  over  it  is  very  promi- 
nent, and  gives  an  obliquity  to  the  whole  countenance  ;  the 
matter  which  runs  from  the  right  nostril  only,  is  in  great  profu- 
sion, it  is  partly  glairy^  partly  purulent,  amounts  to  two  or 
three  ounces  in  the  day,  and  sometimes  entirely  fills  a  bleeding 
palate*.  His  speech,  especially  alter  a  paroxysm,  is  slow,  dif- 
ficult, hesitating,  and  interrupted.  When  pain  of  the  forehead 
comes,  and  is  not  followed  by  convulsions,  he  has  a  general 
feeling  of  weakness,  as  if  all  his  joints  were  loosened  ;  he  trem- 
bles, and  his  knees  shake  under  him,  and  he  has  a  trembling 
and  paralytic  feeling  in  the  arm." 

This  is  the  whole  state  and  condition  of  this  young  man, 
who,  from  uncommon  health,  and  bodily  strength,  is  reduced  to 
great  weakness  and  despondency ;  and  since  the  first  signs  of 
the  paroxysm  are  distinctly  relcrable  to  the  frontal  sinus,  and 
since  the  convulsion  affects  the  same  side  of  the  body  with  the 
injured  part  of  the  head,  all  suspicions  of  its  arising  from  any 
disorder  of  the  brain  are  removed.  I  have  resolved,  (encour- 
aged and  supported  by  the  unanimous  voice  of  the  consulting  sur- 
geons), to  trepan  the  sinus,  hoping,  by  curing  this  ulcer,  to  re- 
move a  possible  cause  of  disorder:  The  dismal  situation,  and 
earnest  intreaties  of  the  patient,  are  arguments  too  powerful  to  be 
resisted  ;  and  the  operation,  though  unusual,  is  no  rash  enter- 
prise, but  on  the  contrarv,  entirely  void  of  danger. 

I  laid  open  the  diseased  and  much  enlarged  sinus  with  an 
incision  of  little  more  than  an  inch  long,  and  perforated  the 
bone,  which  was  of  such  thickness,  that  the  assistants  believed 
that  I  had  mistaken  the  case,  and  pierced  not  the  outfr  plate  of 
the  sinus,  but  the  whole  thickness  of  the  scull ;  and  they  plainly 
said,  that  the  membrane  now  exposed  was  not  the  lining  of  the 
sinus,  but  the  dura  mater.  But  it  was  merely  the  lining  of  the 
sinus  ;  the  injections  passed  from  this  small  trepan-hole,  into  the 
throat  and  nostrils,  and  the  patient  could  at  pleasure  draw  it 
back  again  through  the  trepan- hole.  By  a  little  skill  and  practice, 
and  by  inclining  the  head  of  the  patient  properly,  the  dresser 
soon  learnt  to  direct  his  injection,  so  that  the  whole  of  it  flowed 
out  by  the  right  nostril.  The  lad  continued  under  my  care  for 
three  months,  and  I  injected  the  sore  first  with  barley-water, 
then  with  solutions  of  vinegar  and  honey,  then  with  tinctures  of 

•  Containing  from  four  to  five  ounces. 


256  Of  the  Connections  of  the  Scull. 

bark  and  myrrh,  and  finally  with  tinctures  of  corrosive  sublimate 
and  crude  sal  ammoniac  ;  but  (as  I  must  confess)  without  the 
slightest  alteration  on  the  matter,  (which  ran  profusely  from 
the  nostril),  or  the  slightest  impro\emcnt  of  his  health  :  Des- 
pairing of  doing  good,  and  wishing  that  he  should  leave  the 
precin;ts  of  an  hospital  not  always  healthy,  and  enjoy  his  native 
air  and  better  food,  I  sent  hun  home,  having  first  withdrawn 
the  tent,  and  healed  the  fistula,  which  closed  solidly  in  two 
days,  and  had  always  been  inclined  to  close.  So  untrue  are  all 
these  idle  tales  about  the  danger  of  wounds,  and  the  rashness  of 
trepaning  this  part. 


DISCOURSE  XVII. 


OF  THE  PATHOLOGY  OF  THE  INTEGUMENTS, 
SCULL,  AND  DURA  MATER. 


SECTION    I. 

On  the  Vitality  and  Connections  of  the  Scull. 

x\S  you  are  now  aware  of  the  important  truth,  that  the  rules 
of  our  art  are  not  to  be  deduced  from  the  external  forms  of  the 
scull,  I  shall  now  begin  to  unfold  the  true  theory  of  injuries  of 
the  brain,  by  explaining,  not  the  outward  form  of  the  cranium 
and  the  anatomy  of  its  several  bones,  but  the  internal  organiza- 
tion, the  living  powers,  the  susceptibility  of  injury,  and  the 
sympathy  of  the  pericranium,  the  scull,  and  dura  mater  with 
each  other  : — these  are  the  integuments  of  the  brain,  and  from 
the  s-ightest  injury  of  the  most  remote  of  these,  there  often  en- 
sues, slowly,  imperceptibly,  and  at  a  distant  and  unsuspected 
period.,  suppuration  of  the  brain  itself.  Life  is  endangered 
more  frequently  by  a  laceration  of  the  integuments,  or  by  a 
mere  contusion  ol  th<  scull,  or  by  an  imperceptible  separation 
of  the  dura  mater,  than  by  the  widest  fractures.  Now,  the 
proofs  of  this  consist  in  facts,  which  even  in  their  simple  de- 
tail, though  not  connected  by  theory,  nor  recommended  by  any 
ingenious  explanation,  would  be  of  theorist  Ives  useful;  but  the 
mutual  dependence  of  the  scalp,  the  scull,  and  the  dura  mater 


Of  the  Connections  of  the  Scull.  25/ 

is  so  clearly  made  out  by  innumerable  practical  examples:  the 
progress  of  disease,  from  a  slight  puffy  tumour  of  the  scalp,  to  a 
fatal  suppuration  of  the  dura  mater,  is  so  plainly  traced ;  the 
slow  but  undeviating  progress  ol  fatal  signs,  from  the  first  nau- 
sea, and  slight  tremblings  of  the,  hands  and  tongue,  to  the  fatal 
convulsions,  is  so  easily  traced,  and  forms  so  interesting  a  sub- 
ject for  judicious  prognostics,  and  sensible  and  manly  practice, 
that  I  know  not  in  the  circle  of  our  profession  a  piece  of  pathol- 
ogy more  intelligible,  nor  a  subject  ol  inquiry  more  easily  pro- 
secuted, to  sure  and  interesting  conclusions.  And  we  have 
this  encouragement  to  consider  the  pathologv  in  place  of  the 
anatomy  of  the  scull,  as  the  rule  of  our  prognostics,  that  while 
anatomy,  and  the  enumeration  and  classify  ation  of  fractures, 
has  led  to  an  undue  propensity  to  operation,  the  study  ol  the 
living  powers,  and  mutual  dependence  of  these  parts,  leads  to 
a  reserved,  modest,  and  rational  practice, — to  a  just  confidence 
in  the  powers  of  nature, — to  a  careful  and  solicitous  attention  to 
all  the  insidious  symptoms  of  suppurating  brain. 

The  integuments  or  scalp,  i.  e.  the  successive  layers  of  the 
slcin,  occipito-frontalis  muscle,  cellular  substance,  and  pericra- 
nium, are  closely  connected  with  each  other,  and  with  the  scull, 
by  one  continued  tissue  of  vessels.  When  these  integuments 
are  separated  from  the  scull,  even  in  the  dissection  of  the  dead 
body,  the  scull  sweats  out  drops  of  blood  from  every  point  of 
its  surface.  The  outer  table  of  the  scull  is  so  plainly  alive,  that 
the  surgeon  can  perfectly  judge  of  its  death  :  when  alive,  it  is 
moist,  clear,  and  bleeds  upon  being  perforated;  it  is  by  its  dry- 
ness and  faded  colour,  and  its  bloodless  appearance,  (and  when 
trepaned,)  by  the  dryness  of  the  dust  turned  out  in  sawing, 
that  the  surgeon  is  able  to  pronounce  it  carious  and  dead.  The 
scull  is  nourished,  vet  not  altogether  dependent  for  its  circula- 
tion on  its  periosteum  and  scalp:  a  piece  of  scalp  may  not  on- 
ly be  raised  by  a  clean  cut  of  the  sabre,  and  laid  down  again  so 
as  to  adhere  to  the  hone,  as  to  any  soft  part,  but  being  cut  off, 
it  is  replaced,  in  part  at  least,  by  granulations  from  the  scull. 
The  integuments  not  cut,  but  lacerated,  detached  from  the  scull, 
flapped  down  over  the  face  and  ears,  soiled  with  earth  and 
mud,  will,  upon  being  cleaned,  and  laid  in  their  place,  adhere 
to  the  scull. 

The  scull  re-unites  thus  easily  with  the  integuments,  from  hav- 
ing every  essential  provision  for  life  and  circulation  within  itself. 
It  is  by  means  of  the  same  provision  that  when  large  and  broad 
pieces  of  the  scull  are  apparently  insulated  by  fractures  sur- 
rounding the  piece  of  bone  on  all  sides,  with  the  dura  mater  as 
completely  detached  from  the  internal,  as  the  pericranium  is, 
by  laceration,  or  by  scraping,  from  the  external  surface  of  the 

2K 


258  Of  the  Connections  of  the  Scull. 

bcuII,  and  after  being  depressed  by  violence,  are  as  violently 
raised  by  working  with  the  levator,  that  they  live  and  are  re- 
united, and  granulate  and  heal. 

The  circulation  thus  maintained  by  the  pericranium  from 
without,  so  vigorous  in  the  structure  of  the  bone  itself,  is  like- 
wise well  supported  from  within  ;  for,  indeed,  if  we  were  to 
assign  the  nourishment  of  the  scull  to  any  one  source,,  it  would 
be  to  the  dura  mater,  which  is  more  properly  the  internal  peri- 
osteum of  the  scuil,  than  a  membrane  belonging  to  the  brain  ; 
with  the  brain  it  has  no  vascular  connection,  but  is  separated  by 
a  halitus  or  secretion  similar  to  that  of  other  cavities,  as  those  of 
the  pericardium  or  peritona?um  :  with  the  scull  it  is  so  connect- 
ed, that  the  scull-cap  is  in  dissection  torn  up  with  the  greattst 
force,  and  tverv  point  is  covered  with  the  ruptured  mouths  of 
delicate  and  bleeding  vessels. 

The  dura  mater  is  very  firmly  attached  to  the  whole  internal 
surface  of  the  scull ;  it  is  hard,  firm,  grates  like  a  cartilage  when 
cut  with  scissors,  and  has  a  glistening  surface,  like  the  capsule 
of  a  joint :  it  has  no  appearance  of  delicacy  or  sensibility,  for 
indeed  it  has  none,  since  acids,  caustics,  and  even  the  actual 
cautery,  have  been  applied  to  it,  and  it  has  been  cut  and  torn  in 
experiments  on  living  animals,  without  exciting  pain.  It  enters 
very  slowly  into  diseased  action,  and  has  as  little  appearance  of 
vascularity  as  of  sensibility ;  often  it  is  inflamed,  and  even  sup- 
purated, without  changing  colour,  and  is  little  affected  by  our 
most  subtile  injections.  But  the  injection,  which  does  not 
change  the  colour  of  the  dura  mater,  colours  the  bone,  passes 
through  its  vessels,  and  runs  out  from  innumerable  minute  ori- 
fices, when  the  dura  mater  is  torn  away:  it  appears  from  every 
circumstance,  that  the  vascularity  of  the  dura  mattr  is  destined 
for  the  nourishment  of  the  scull,  and  may  be  truly  named  its 
Internal  Periosteum:  and  the  great  arteries  and  veins  (as  they 
are  called)  of  the  dura  mater,  might  be  more  justly  described  as 
the  Nutritious  Vessels  of  the  scull.  Were  we  first  to  observe 
this  vascular  connection,  and  then  glance  our  eye  hastily  over 
the  facts  relating  to  it,  we  should  be  apt  to  pronounce  the  scull 
entirely  dependent  for  its  nourishment  on  the  dura  mater ;  and 
that  its  connection  cannot  be  dissolved  by  disease,  without  cor- 
ruption of  the  bone,  and  suppuration  of  the  brain,  nor  detached 
by  violence,  without  effusion  of  blood.  Yet  this  important 
source  of  nourishment,  the  scull  can  also  dispense  with,  and 
live  ;  for,  in  cases  of  the  most  extensive  effusions  of  blood  un- 
der the  scull,  and  where  this  membrane  is  divided  from  it  by 
a  thick  and  solid  cake  of  coagulated  blood,  wc  find,  that  the 
scull  bleeds  in  trepaning,  and  granulates  during  the  cure  ; 
jmd  although  it  may  seem  a  fact  difficult  to  ascertain,  I  shall 


Of  Injuries  of  the  Scalp.  259 

prove  to  your  conviction,  that  the  dura  mater  may  by  a  shock  be 
detached  from  the  scull,  and  adhere  again  to  it  without  harm, 
leaving  unequivocal  marks  by  which,  in  dissection,  it  can  be 
known  that  it  had  been  separated  and  re-united. 

I  take  a  pleasure  in  submitting  to  your  review  these  facts,  so 
opposite  to  the  doctrines,  and  so  inimical  to  the  practice  of  the 
older  surgeons  ;  for  they  will  teach  you,  if  you  dwell  upon  them, 
to  have  a  perfect  confidence  in  the  powers  of  nature.  With  so 
many  sources  of  circulation,  the  life  of  the  scull  is  very  secure  : 
the  scalp,  the  scull,  and  the  dura  mater,  are  the  successive  in- 
teguments of  the  brain,  they  mutually  support  each  other,  so 
that  they  cannot  be  individually  injured  ;  and  we  have  reason  to 
believe,  that  when  the  dura  mater  suppurates,  and  the  brain  is 
endangered,  the  whole  system  of  this  vascular  connection  has 
suffered  a  fatal  shock,  or  the  bone,  the  centre  of  that  circulation, 
has  been  deadened  by  the  blow.  I  fear  that  those  general  con- 
clusions, which  by  a  sort  of  anticipation  I  have  laid  before  you, 
may  seem  more  allied  with  speculation  than  practice,  yet  are 
they  the  true  and  genuine  source  of  your  prognostics. 

SECTION   II. 

Of  injuries  of  the  Scalp. 

However  extensive  the  laceration,  if  the  scull  be  uninjured, 
the  scalp  not  irrecoverably  bruised,  the  patient  in  health,  and 
not  exposed  to  contagion  or  fever,  it  may  (with  only  slight  and 
partial  interruptions)  be  made  to  adhere  again  to  the  bone.  Of 
such  recoveries,  every  practical  surgeon  has  seen  examples, 
and  many  interesting  cases,  made  remarkable  by  the  circum- 
stances of  the  accident,  are  recorded. 

The  following  case  is  related  by  Mr.  Hill :  tf  A  drunken  coun- 
try-man, aged  about  sixty-six  years,  riding  furiously  along  the 
street,  was  flung  with  such  force  against  the  sharp  edge  of  a 
door-post,  that  about  the  length  and  breadth  of  a  hand  was  strip- 
ped off  the  right  side  of  his  head,  and  laid  down  on  the  cheek. 

".  Some  people,  in  the  dark,  took  his  wig  out  of  the  kennel, 
and,  not  knowing  what  had  happened  to  his  head,  put  it  on  full 
of  mud,  and  squeezed  his  hat  over  it.  He  did  not  complain 
of  his  head,  but  complained  greatly  of  his  neck  and  shoulders. 

"  The  dirt  was  rubbed  into  the  Tunica  Cellulosa  in  such 
a  manner,  that  it  was  impossible  to  clean  it  fully  out.  I  there- 
fore pulled  up  the  loose  piece  of  the  scalp,  and,  after  washing 
and  stuffing  it  with  soft  liniments,  put  four  stitches  into  the  up- 
per part,  but  so  loosely,  as  to  allow  the  matter  a  free  passage. 

"  The  wound  digested  so  well,  that  in  five  days  all  danger- 


260  Of  Injuries  of  the  Scalp. 

ous  symptoms  were  over,  and  his  friends  carried  him  home 
without  acquainting  me.  Having  no  proper  person  to  take  care 
of  him,  tht-  stitches  gave  way,  one  after  another,  and  it  hcaUd, 
leaving  near  two  fingers- breadth  of  the  scull  bare,  the  teguments 
lying  in  folds  on  the  Os  Petrosum.  This  circumstance  might 
easily  have  been  prevented  by  renewing  the  stitches.  He, 
however,  lived  and  enjoyed  good  health  above  twenty  years." 

Yet  a  laceration  of  the  scalp  is  a  state  of  danger  and  uncer- 
tainty. We  never  can  be  assured  that  the  bone  is  not  too  much 
injured  to  admit  of  its  rt-uniting  with  the  scalp,  or  that  the 
constitution  is  not  too  weakly,  or  the  season  or  the  air  unfa- 
vourable ;  we  never  can  be  assured,  even  when  the  prospect  at 
first  is  most  flattering,  that  a  laceration  of  the  scalp  will  not  be 
followed  by  a  suppuration  of  the  brain. 

"  Thomas  Sharpe  was  an  itinerant  dancing-master,  a  fidler, 
a  performer  in  a  military  band  ;  he  died  trumpeter  to  the  Dum- 
frieshire  militia,  and  had  attained  to  all  the  perfection  of  liber- 
tinism, and  dissolute  behaviour,  that  such  occupations  natural- 
ly entail  upon  those  who  practice  them.  One  morning,  reel- 
ing out  of  a  low  tavern,  he,  after  scrambling  up  the  stairs  of  it, 
staggered  forwards  into  the  unguarded  area  of  a  house  that  was 
building,  and,  without  any  other  apparent  injury,  had  his  scalp 
torn  down  over  his  face.  The  scalp  was  ragged  in  its  edges, 
and  mangled  every  where,  with  several  penetrating  wounds  ; 
it  was  separated  from  the  whole  upper  part  of  the  head,  lrom 
the  lambdoid  suture  nearly  to  the  eye-brow,  and  from  the  ver- 
tex to  the  right  car  ;  much  of  the  scull,  and  especially  of  the  os 
frontis  of  that  side  of  the  head  was  laid  bare  :  nor  was  the  op- 
posite side  without  bruises,  and  lesser  wounds,  for  it  seemed  to 
have  been  jammed  in  among  the  loose  stones. 

u  The  scalp  was  sponged,  cleaned,  and  dried,  and  smoothly 
applied  again  to  the  scull ;  and  as  the  edges  of  the  laceration 
were  irregular,  and  bruised,  and  in  no  fit  condition  to  be  nicely 
joined  with  stitches,  they  were  held  by  plasters  onl) ,  they  were 
united  in  a  few  days  with  each  other,  and  even  seemed  re-united 
on  the  lower  surface  with  the  surface  of  the  scull ;  whatever 
inflammation  there  was,  seemed  a  very  natural  consequence  of 
the  general  bruises,  and  lesser  wounds  of  the  scalp;  and  we 
were  confirmed  in  this  good  expectation,  from  the  man's  hav- 
ing recovered  from  his  intoxication,  and  continuing  in  apparent 
health.  He  felt  his  bruises,  and  complained  of  the  pain,  slept 
well,  had  neither  delirium,  sickness,  nor  fever,  and  was  bled 
only  on  account  of  the  fulness  of  the  pulse. 

"  On  the  fifth  day,  the  little  discharge,  which  issued  from 
the  irregular  openings,  and  smaller  wounds,  was  good ;  the  ad- 
hesion continued  apparently  sound ;  on  the  sixth,  the  discharge 


Of  Injuries  of  the  Scalp.  261 

from  under  the  scalp  was  more  copious,  and  compresses 
were  nicely  applied  to  keep  the  scalp  and  the  scull  in  contact 
with  each  other.  On  the  eleventh  day  it  became  necessary, 
from  fluctuation  and  softness  in  all  the  lower  part  of  the  de- 
tached scalp,  to  make  an  opening  over  the  ear  for  the  discharge 
of  matter,  which  flowed  so  profusely,  and  was  accompanied 
with  such  fits  ot  rigour,  that  I  abandoned  all  hopes  ot  any  firm 
or  general  re-union,  and  began  to  fear  that  the  brain  was  in  a 
state  of  suppuration.  Upon  pushing  the  probe  through  the  soft 
and  downy  granulations  which  united  the  edges  ot  the  scalp 
with  the  scull,  I  was  persuaded,  that  all  below  the  mere  edge 
was  disengaged,  that  the  whole  extent  of  the  parietal  bone  was 
rough  and  naked.  The  probe,  in  its  progress  between  the  scull 
and  integuments,  encountered  what  all  my  assistants  conceived 
to  be  a  fracture  of  the  scull;  yet  still  the  patient  retained  his 
senses,  and  suffered  little  in  his  health. 

M  The  symptoms  of  suppurated  brain  are,  as  I  know  from 
much  experience,  far  from  alarming  when  they  first  appear. 
The  detached  state  of  the  scalp,  the  roughness  of  the  bone,  the 
profusion  of  matter  which  flowed  through  all  the  openings,  and 
the  slight  rigours,  dejected  looks,  and  tremblings  of  the  hand 
and  tongue,  though  they  are  such  as  alarm  the  surgeon,  can 
hardly  vindicate  him  in  taking  any  decisive  step.  I  was  per- 
suadtd  that  the  bone  was  dead,  and  the  brain  in  a  state  of  sup- 
puration :  I  saw  no  prospect  of  interposing  with  success  at  so 
late  a  period  as  the  sixteenth  day  from  the  injury  :  I  was  sup- 
ported by  the  consulting  surgeons  in  the  preliminary  step  of 
opening  the  scalp,  and  exposing  the  diseased  bone ;  but  they 
seemed  to  suffer  a  disappointment,  when  that  rough  line,  which 
was  so  curiously  traced  with  the  probe,  was  found  not  to  be  a 
fracture,  and,  as  there  was  no  fracture,  I  was,  fortunately  for 
my  reputation,  prevented  from  applying  the  trepan  ;  for  though 
there  was  every  motive  for  operating,  the  patient  died  next  day 
of  a  disease,  inevitably  latal,  connected  indeed  with  the  acci- 
dent, but  having  no  relation  to  the  state  of  the  brain. 

u  Let  me  now,  then,  proceed  to  give  vou  an  account  of  the 
condition  of  this  man  before  the  operation,  of  the  manner  of 
his  death,  and  of  the  appearance  on  dissecting  the  body.  Be- 
fore the  operation  of  cutting  up  the  seal,),  there  were  no  deci- 
sive signs,  nor  fatal  prognostic  ;  for  of  all  the  fatal  affections  of 
the  brain,  this  of  suppuration  ot  the  dura  mater  is  the  most  in- 
sidious in  its  progress ;  and  our  patient,  before  we  apprehend 
him  to  be  in  danger,  is  in  general  beyond  the  reach  of  help. 
This  man,  though  he  had  the  cranium  naked,  the  scalp  in  full 
suppuration,  and  a  profusion  of  thin  matter  pouring  out  from 
various  openings,  had  no  other  symptoms  than  slight  rigours, 


262  Of  Injuries  of  the  Scalp. 

and  no  more  violent  rigours,  indeed,  than  often  accompany  the 
slight  fever  of  a  lacerated  scalp.  It  was  towards  the  sixteenth 
day,  perhaps  about  the  fourteenth,  that  these  rigours  were  fol- 
lowed with  a  sweating  stage,  that  they  became  sensibly  more 
frequent  and  violent,  and  that  they  were  accompanied  during 
the  day  with  unusual  languor,  and  in  the  night  with  a  slight  de- 
lirium, which  disappeared  only  when  he  was  thoroughly  roused 
from  sleep.  Yet,  at  this  most  critical  period,  I  could  not  make 
him  say  that  he  had  any  corded  feeling  over  the  brow,  any  head- 
ach,  any  thing  which  might  indicate  to  his  own  apprehension 
a  disorder  within.  I  could  not  perceive  the  slightest  wavering 
in  his  intellect  ;  I  could  not  find,  in  the  irritable  state  ol  his 
pulse,  the  foulness  of  his  tongue,  the  dulness  of  his  eye,  in  his 
perturbed  sleep,  and  alarming  dreams,  any  thing  more  than 
the  feverish  disorder  naturally  accompanying  so  extensive  a  la- 
ceration of  the  scalp  ;  and  yet  at  that  moment  was  the  suppura- 
tion of  the  dura  mater  fairly  established,  and  the  brain  itself 
deeply  tainted. 

"  An  increased  drowsiness,  with  rigours  more  violent  than 
usual,  a  degree  of  headach,  and  a  sensibility  to  light  induced, 
us,  upon  the  sixteenth  day,  to  cut  up  the  slight  adhesion  oi  this 
great  flap  of  suppurated  scalp,  which  immediately  fell  over  the 
ear,  and  left  the  whole  parietal  bone  exposed,  in  a  condition 
perfectly  decisive,  in  my  opinion,  of  the  state  of  the  brain,  and 
indeed  of  the  patient's  fate.  There  was  a  portion  of  the  parie- 
tal bone  broad  as  the  palm  of  my  hand,  of  a  square  form,  appa- 
rently insulated  from  the  rest,  black,  carious  and  elevated, 
above  the  level  of  the  surrounding  bone,  and  circumscribed  by 
a  line  as  decisive  as  if  it  were  a  fracture.  This  part,  which  was 
the  centre  of  the  parietal  bone,  was  rough,  dry,  and  promi- 
nent, of  a  dark  yellow  colour,  engrained  with  black  spots  like 
a  toad's  back.  The  pores  of  the  bone,  or,  in  other  terms,  the 
minute  and  almost  invisible  holes  by  which  the  blood-vessels 
enter  it,  seemed  wide,  and  not  red  as  when  blood  is  circulating, 
but  black.  In  the  margin  immediately  surrounding  this,  where 
the  bone  was  still  alive,  and  in  a  state  of  ulceration,  the  bone 
was  wasted,  so  that  the  carious  part  was  left  prominent,  with  a 
line  so  fairly  circumscribed,  that,  when  felt  with  the  probe,  it 
might  be  mistaken  tor  fracture  ;  this  is  indeed,  uniformly  the 
condition  of  a  dead  and  exfoliating  piece  of  the  scull.  Beyond 
this  ulcerating  circle,  where  the  integuments  and  muscles  ad- 
hered, they  adhered  with  particular  firmness, being  crammed  with 
extravasated  blood,  and  hardened  by  inflammation.  Though  the 
certainty  of  the  brain  being  in  a  state  of  suppuration,  inclined 
me  to  perforate  the  cranium,  the  certainty  now  of  there  being 
no  fracture  inclined  my  assistants,  and  the  consulting  surgeons, 


Of  Injuries  of  the  Scalp.  26S 

to  refuse  their  consent  to  that  operation,  which  alone  could  save 
our  pnient  :  thus  I  was  destined  to  escape  the  opprobrium  of 
having  shortened  the  life  of  a  man,  whose  death,  lrom  a  very 
different  cause,  was  inevitable. 

"  He  was  perfectly  sensible  during  this  preliminary  operation, 
and  would  most  willingly  have  consented  to  any  measure  we 
might  judge  expedient.  But,  when  he  was  conveyed  to  bed, 
he  seemed  weak,  his  breathing  was  low  and  difficult,  his  pulse, 
which  had  beat  124  in  the  afternoon,  was  this  evening  extremely 
feeble  and  slow,  and  he  broke  out  into  a  very  profuse  sweat. 
His  leatures  were  shrunk,  and  his  face  pale  and  ghastly.  A- 
bout  four  in  the  morning  he  was  seized  with  sickness  and  se- 
vere vomiting,  and  with  a  rigour,  which  lasted  fully  twenty 
minutes,  and  at  eleven  in  the  morning  his  breathing  was  ex- 
tremely oppressed  ;  it  was  painlul  to  witness  his  struggles  for 
breath,  and  the  anxiety  and  cold  sweats  which  it  brought  upon 
him  :  in  half  an  hour  after  his  most  violent  struggle  for  breath, 
he  was  seized  with  a  profuse  haemorrhage  from  the  lungs, 
brought  up,  with  coughing  and  struggling,  fully  a  pound  of  flo- 
rid blood,  and  expired.  Thus,  in  the  very  moment  in  which 
he  came  into  manifest  danger  from  suppuration  of  brain,  he 
died  from  the  bursting  of  a  blood-vessel  in  the  lungs.  What 
bruises,  besides  the  wounds  of  the  head,  he  may  have  received 
unconsciously  in  his  state  of  intoxication,  we  do  not  know  ;  but 
nothing  is  more  likely,  than  that  in  the  fall  which  thus  hurt  his 
head,  the  lungs  had  also  suffered  material  injury  ;  it  is  perhaps 
from  such  injuiies  passing  unnoticed,  that  suppuration  ot  the 
liver  so  frequently  accompanies  fractures  of  the  scull  ;  indeed, 
I  know  not  how  a  man  can  fall  from  a  height,  without  so  heavy 
a  viscus  as  the  liver  suffering  by  the  shock,  independent  of  any 
direct  blow. 

*  The  appearances  on  dissection  were  as  follow  :  The  ap- 
pearance of  the  brain  implied  danger  ;  but  it  was  the  dissection 
of  the  lungs  that  explained  his  sudden  death.  Upon  raising 
the  cranium,  all  that  surface  of  dura  mater  which  lay  un- 
der the  diseased  bone  was  in  full  suppuration,  covered  with 
white  and  mature  matter,  and,  in  many  points,  perforated  with 
ulceration.  The  pia  mater,  in  contact  with  the  diseased  dura 
mater,  was  not  yet  ulcerated,  for  the  brain  cut  sound  and  firm 
up  to  the  very  surface ;  yet  the  whole  mass  of  the  brain  was  in 
some  degree  affected,  an  increased  action  of  its  vessels  had 
unquestionably  taken  place,  for  all  the  ventricles  were  enlarged, 
and  full  of  serum,  but  not  obviously  inflamed.  Tbus  our  pa- 
tient was  in  that  state  of  danger  from  suppuration  ot  the  brain, 
lrom  which  so  few  are  recovered  even  by  the  most  timely  ope- 
rations ;  but  the  sudden  bursting  of  a  great  vessel  iu  the  lungs 


264  Of  Injuries  of  the  Scalp. 

was  the  immediate  cause  of  the  death ;  for,  upon  opening  the 
right  side  of  the  thorax,  there  was  found  in  the  lungs  ot  the 
right  side  a  great  effusion  of  blood,  and  a  small  superficial  ulcer 
on  the  largest  lobe  ot  this  part  of  the  lungs." 

Whether  is  it  to  the  mere  laceration  of  the  scalp  that  we  are 
to  refer  all  this  disorder  ?  Was  the  scalp  so  mangled  bv  the 
sharp  and  irregular  stones  among  which  this  man  had  fallen', 
was  it  perforated  in  so  many  places  by  these  irregular  wounds 
I  have  mentioned,  as  to  destroy  its  texture,  and  make  it  no 
longer  capable  of  maintaining  its  connection  with  the  scull  ?  Or, 
was  the  bone  itself  so  much  injured  in  its  internal  structure  and 
circulation  as  to  be  incapable  of  pushing  out  granulations  to  meet 
those  of  the  scalp  ?  Does  not  the  practice  here  pursued,  of 
holding  the  scalp  in  its  place,  of  supporting  partial  adhesions, 
and  endeavouring  to  extend  them  by  using  compresses,  and 
confining  the  inflamed  scalp  in  contact  with  the  diseased  bone,- 
tend  rather  to  increase  that  inflamm  ition,  and  indeed  to  widen 
the  separation  ?  Were  not  those  symptoms  of  shiverings  and 
languor  which  (slight  though  they  be)  indicate  suppuration  of 
the  brain,  too  long  neglected  ?  Should  I  not  in  place  of  making 
successive  openings,  when  new  abecsses  were  generated,  have 
thrown  down  the  scalp  to  examine  the  bone  ?  Should  I  not, 
according  to  the  strict  rules  of  good  sense  and  good  surgery, 
have  proceeded  to  trepan  a  scull,  carious  to  such  extent,  unequiv- 
ocally dead,  quite  incapable  of  maintaining  any  connection  with 
the  dura  mater,  sure,  on  the  contrary,  to  operate  upon  it  as  a 
foreign  body,  and  to  produce  suppuration  ?  For  this  was  not 
one  of  those  circumscribed  and  superficial  exfoliations,  which 
can  be  thrown  off  without  danger  to  the  brain.  Finally,  since 
this  patient  survived  so  horrible  an  injury  for  three  weeks,  and 
died  by  a  sort  of  accident,  is  not  the  long  delay  of  this  fatal 
suppuration  a  sort  of  proof,  that  it  happened  not  from  primary 
separation  of  the  dura  mater  detached  by  the  shock,  nor  by  a 
secondary  separation  depending  on  slow  disease  of  the  bone, 
but  from  this  destruction  of  the  scalp,  followed  in  succession 
by  death  of  the  scull,  and  suppuration  of  the  dura  mater,  the 
internal  periosteum  of  the  scull  ? 

Though  I  regard  every  fatal  case  as  an  occasion  of  reflection, 
and  almostof  self-reproach,  yet  I  am  sensible  that  this  case  was 
too  complex  not  to  admit  of  many  apologies :  There  are  in  such 
cases  of  lacerated  scalp  certain  irregularities  and  anomalies 
which  incline  me  at  all  times  to  proceed  with  caution.  There 
are  conditions  of  the  individual  systems,  and  varieties  of  climate, 
or  air,  which,  without  any  local  cause,  without  the  scalp  or  the 
scull  being  essentially  ruined  in  their  texture,  prevent  their  re- 
union, and  even  occasion  death.   The.  air  of  particular  countries 


Of  Injuries  of  the  Scalp.  265 

has  been  remarked  through  ages  as  peculiarly  noxious  to  those 
wounded  in  the  head.  Lusiiani  has  celebrated  "  the  noxious 
air  of  Florence  and  Bologna,  while  the  air  of  Ragusa,  seated 
upon  a  rock,  is  so  extremely  favourable,  that  even  where  the 
cranial  bones  are  fractured  and  destroyed,  hardly  any  patient 
dies,  but  all  recover." 

The  ill  air  of  an  hospital  is  more  fatal  to  the  re-union  of  the 
scalp,  than  either  the  bruising  of  the  scalp,  or  the  injury  or 
contusion  of  the  bone.  The  air  of  the  hospital,  the  HoteU 
Dieu,  in  Paris,  is  more  noxious  than  the  climate  of  Cremona, 
Florence,  or  Mantua,  and  has  been  a  matter  of  regret  in  all 
ages  The  good  old  surgeon,  Saviard,  shows  us  what  danger 
there  is  in  making  even  the  slightest  incisions,  by  a  case  in- 
structive in  man)  respects. 

"  Nurse  Bernard  of  the  Hotel-Dieu,  no  more  than  twenty- 
three  years  of  age,  was  struck  on  the  back  of  the  head  by  the 
falling  of  a  pole,  set  up  for  drying  clothes,  and  fell  senseless  to 
the  ground.  Upon  giving  her  a  little  eau  de  vie,  she  revived, 
when  there  was  observed  upon  the  injured  part  a  small  bump 
only,  of  the  size  of  a  nut,  and  without  any  wound. 

"  The  same  evening  she  vomited,  and  was  oppressed  at  in- 
tervals with  a  degree  ol  stupor,  which  having  continued  four 
days,  we  became  anxious,  (says  Saviard),  and  resolved  to 
open  the  tumour,  which  was  full  of  coagulated  blood,  the  peri- 
cranium adhering  soundly  to  the  scull  beneath.  From  this  time 
forward  she  had  irregular  shiverings,  which  lasted  at  each  return 
four  hours  uninterruptedly ;  and  during  the  seventeen  davs  in 
which  they  continued,  we  reckoned  twentv-five  returns.  Bleed- 
ing we  were  so  little  sparing  ol,  that  in  the  first  days  of  her  ill- 
ness we  bled  her  no  less  than  fourteen  times  in  the  arm,  and  once 
in  the  ankle  j  her  vomiting  continued  incessantly,  accompanied 
with  pungent  pain  in  the  region  of  the  liver. 

"  Alter  the  seventeenth  day,  gangrene  came  upon  the  wound, 
which  forced  us  to  make  repeated  incisions  ;  bad  svmptoms 
continued,  notwithstanding,  for  forty  days,  and  two  months 
and  a  fortnight  had  expired  before  the  wound  closed.  Nor 
did  her  sickness  end  here,  for  shortly  after  the  closing  of  the 
wound,  her  face  was  puff.d  up  with  an  (Edematous  swelling, 
much  serum  running  continually  by  the  ears  and  nostrils  for 
fifteen  days  ;  deafness  supervened,  with  lancing  pains,  and  con- 
tinued disorder  of  the  head  ;  more  than  a  pint  of  reddish  mat- 
ter flowed  from  the  nose,  and  a  rheum  inundated  the  chest, 
and  threatened  suffocation  to  such  a  degree,  that  for  a  long  while 
we  looked  for  nothing  but  sudden  death.  It  were  impossible 
to  enumerate  (besides  the  twenty-six  bleedings)  the  various 
medicines  she  used;  it  was  by  the  frequent   use  of  ass's  milk 

2L 


266  Of  Injuries  of  the  Scalp' 

that  her  health  was  at  last  restored.  Her  pains  in  the  head 
continued  lor  two  years,  with  beating  of  the  temples  which  in- 
creased with  every  change   of  the  weather." 

Without  having  the  misfortune  to  have  served  in  any  hospital, 
where,   to  use  the  language   of  Saviard,  **  I    saw   innumerable 
victims,'"  or,  being  driven  to  absolute  despair,  like   Dessault,* 
and  abandoning  all  hopes  of  being  useful  in  wounds  of  the  head, 
I  have  yet  learnt  a  degree  of  caution,  with  which  I  would  fain 
impress  vou  in  your  first  conceptions-,  lor  of  all  the  abuses  ot 
practice,  the  most  grievous  to  one  who  reflects  soberly  and  mo- 
destly on  what  art  can  do,  is  the  confident  and  presumptuous 
hope  which  young  men   are  too   apt  to  indulge,  of  re-uniting 
every  piece  of  lacerated  scalp  by  the  main  force  of  sutures,  and 
relieving  every  svmptom  of  oppression,  or   slight  delirium,  or 
temporary    fever,  by   trepaning  the  scull.       I   have  often  ob- 
served, that  though  the  season   seemed  favourable,    the  heat 
moderate,  and  the  air  of  an  hospital  untainted;  while  other  pa- 
tients, and  less  important  wounds,  were  recovering  a-pace,  and 
no  sign  of  infection  could  be  perceived,  those  wounded  in  the 
scalp  became,  after  a  few  days  confinement,  languid,  feverish, 
and  oppressed,  and  had  every  usual  symptom  of  an  oppressed 
brain.       Not  to  specify  innumerable  cases,  from  which  my  ge- 
neral observation  is  deduced,  1    have  seen   a   boy  whose  scalp 
was  lacerated  so  very  largely,  as  to  shew  the  scull  naked,  but 
uninjured,  continue  well,   and  free  from  fever  or  delirium  se- 
veral days,  then  seized  with   vomiting,  like   that  of  oppressed 
brain,  with  rigours  and  foul  tongue,  and  rapid  pulse,  and  deliri- 
um.      I  have  seen  a  boy   lying  in  this  doubtful  and  dangerous 
state  for  fifteen  days,  the  suppuration  of  the  wound  being  inter- 
rupted, and    its  complexion   as  much  affected  as  the  general 
health,  exhausted  by    successive  paroxysms  of  fever,  and  yet 
i  n  no  imminent  danger.       I  have  seen  three   soldiers  hurt,  in 
the  confusion   of  a   fire,  from  bricks  or  beams  falling  on  them, 
all  the   three  wounded  in  the  head,  all  seized  at  once  with  the 
same  temporary  fever  and  delirium,  and  yet  not  one  of  them 
in  any  kind  of  danger.       I   have  often  seen,  in  an  aged  person, 
where  the  scull  was  laid  bare  by  a  blow,  the  integuments  slough 
entirely  away,  and  fall  off  in  cakes  as  black  (to  use  the  expres- 
sion of  nurses)  as  the  soot  on  the  pot,  and,  alter  an  interval  of 
imminent  danger,  in  which  even  the  outer  plate  of  the  scull  has 
exfoliated,  I  have  seen  with  admiration  the  scull  push  forth  its 
granulations  with  such  vigour  in  extreme  old  age,  (at  seventy- 
five  years  of  age)  as  to  replace  the  scalp  with  a  broad  and  firm 

*  Defiault  was  fo  unfuccefsful,  that  at  laft  he  renounced  all  thoughts  of  ope- 
rating in  fractures  of  the  fcull,  and  with  a  few  ordinary  precautions  and  remedies, 
abandoned  every  luch  cafe  to  nature. 


Of  Injuries  of  the  Scalp.  267 

cicatrix.  These  accidents  of  fractured  scull,  or  lacerated  scalp, 
are  frequent  only  in  an  hospital ;  and  you  will  often  observe 
your  patient,  whatever  his  agt  or  constitution,  attacked  with 
sickness  or  fever,  which  seems  to  imply  danger,  but  which  is 
to  be  cured  by  antimonials,  opiates,  and  the  warm  bath.  "  Ne- 
ver permit  yourselves  to  be  alarmed  too  much  at  these  first 
symptoms  of  fever,  nor  hurried  into  any  precipitate  step,  for 
many  have  narrowly  escaped  the  knife  and  the  saw,  the  scalping 
process,  and  the  useless  perforation  of  the  scull,  to  whom,  du- 
ring the  continuance  of  such  a  temporary  tever,  the  slightest  of 
these  operations  would  surely  prove  fatal.'1 

That  aphorism  of  Hippocrates,  which  relates  to  the  fever 
of  intoxication,  may  be  transferred,  without  reserve,  to  that  ac- 
companving  wounds  of  the  head.  **  If  a  man  be  so  intoxicated, 
as  to  lie  speecnlcss,  and  he  be  seiz  d  with  fever,  he  is  in  no  dan- 
ger;  but  if  not  seized  with  fever,  he  dies  the  third  day."  We 
mav,  with  much  greater  truth,  pronounce  the  patient  safe,  who, 
having  a  wound  of  the  head,  has  his  delirium  and  vomiting  ex- 
plained bv  concomitant  fever ;  while  he  who  has  the  slightest 
shiverings,  a  less  perceptible  oppression,  and  no  concomitant 
fever,  is  in  a  doubtful  state. 

But  that  a  wound  of  the  integuments,  naturally  slight,  and 
void  of  danger,  may,  by  misconduct,  cause  not  merely  caries 
of  the  bone,  but  suppuration  of  the  brain,  the  following  incident 
will  prove  to  you.     "  A  young  man  of  seventeen  years  of  age, 
was  struck  in  play,  by  one  of  his  companions,  with  a  small  stone 
on  the  left  side  of  the  head,  over  the  parietal   bone.      He  put 
himself  into  the   hands  of  a  sort  of  surgeon,  who  dress,  d  this 
slight  wound   with  a  heavy  hand,  cramming  it  so  with  rough 
lint,  that  the  sore  rankled  and   inflamed,  with  a  daily   wasting 
of  the  integuments.      Yet  the  boy  was  well  in  all  other  respects, 
went  daily  to  market,  and  served  his  master  with  his  usual  ala- 
crity.     I  saw  this  slight  cutaneous  wound  at  the  time  of  his  first 
committing  himself  to   the  hands  of  the  barber,  with  whom  I 
at  the  time  remonstrated  concerning  his  coarse  manner  of  dress- 
ing the  wound  ;  but  he  replied,  "That  it  was  the  duty  of  a  sur- 
geon to  be  cruel,  and  not  faint  hearted.1'     It  was  because  the 
wound  seemed   so  very  slight,  that  I  gave  up  attending  the  lad, 
but  on  the  eighteenth  day,  he   came  to  me  of  his  own  accord, 
desiring  me   to  see  how  things  went  on.      I  found  all  the  sur- 
rounding integuments   fistulous,  down  to  the  bone,  and   there 
was  one  great  access,  full  of  putrid  matter,  which   could  not 
be  emptied  but  bv  pressure  of  the  hand.      I,  ol  course,  advised 
that  this  abscess  should  be  opened  at  its  lower  part,  which  the 
surgeon  promised  to  do. 

"At  this  time  I  had   no   fixed  quarters,  but  was  obliged  to 


268  Of  Injuries  oj  the  Scalp. 

follow  the  royal  army,  so  that  I  was  prevented  from  seeing  the 
patient  lor  some  time  ;  but,  about  tht  twenty -fifth  clay,  1  was 
called  to  him,  and  his  friends  mentioned  to  mt,  that  the  fever 
which  I  found  him  in,  had  continued  lour  dajs.  His  eyes  were 
heavy  and  swelled  ;  he  was  in  asortol  stupor,  and  was  reduced 
to  extremt  weakness.  The  S'ltus  was  still  unopened,  and  con- 
tained Very  fetid  pus  ;  lor  this  blockhead  01  a  barber  had,  either 
through  pride  orlcar,  altogether  neglected  what  I  advised. 

"  1  had  now  no  reason  to  doubt  that  the  brain  was  affected, 
and  proposed  that  the  integuments  should  be  laid  open,  and  the 
bone  perlorated,  thinking  a  doubtlul  remedy  prelerablc  to  cer- 
tain death.  But  the  presumptuous  iool,  when  he  heard  that 
I  had  proposed  to  perforate  the  scull,  protested,  "  1  hat  it  it 
were  not  for  the  fever,  or  if  the  fever  should  cease,  he  could 
make  the  cure  of  the  wound  a  very  easy  matter. 

"  On  the  twenty-sixth  day,  this  young  man  expired  :  I  re- 
quested that  his  bod)  might  he  opened,  and  the  empyric  con- 
sented with  ail  possible  alacrity,  assured  in  imagination  that  his 
patient's  death  proceeded  merely  lrom  fever,  not  Irom  any  in- 
jur)- of  the  head;  and  in  this  presumption  he  was  hardened  by 
recollecting,  that  from  the  first  there  was  no  sign  nor  appear- 
ance of  any  injury  to  the  bone. 

u  Upon  opening  the  head,  the  cranium  was,  indeed,  found 
free  from  fracture ;  but  there  was  found  betwixt  the  scull  and 
dura  mater  a  considerable  quantity  of  matter,  the  brain  being 
at  that  place  suppurated,  and  melted  into  pus."* 

Thus  are  we  assured,  that  the  mere  detachment  of  the  scalp 
(if  it  continue  detached)  will  destroy  the  scull,  and  endanger 
the  brain  ;  for,  though  it  has  (in  the  dura  mater,  and  in  its  own 
structure)  various  sources  of  nourishment,  though  it  is  little 
injured  bv  a  temporary  or  partial  privation  of  blood,  yet  the 
permanent  separation  of  the  pericranium  manifestly  kills,  de- 
stroys at  least,  the  outer  portion  ol  it,  and  sometimes  its  whole 
thickness.  In  the  older  times,  when  the  doctrine  of  exfoliation 
prevailed,  when  they  were  in  the  practice  of  cutting  off  the  scalp, 
so  as  to  occasion  the  death  of  the  scull,  when  the  separation  of 
the  dead  part  was  mistaken  for  an  essential  process  in  the  cure, 
it  was  reckoned  the  duty  of  the  surgeon  to  procure  exfoliation 
in  every  wound  of  the  scalp  ;  and  he  attained  his  end  by  remov- 
ing the  scalp,  and  by  scraping  and  cauterising  the  bone. 

In  modern  surgery,  nothing  is  to  be  seen  at  all  correspond- 
ing with  this ;  the  scalp  is  never,  by  any  accident,  kept  separate 
from  the  scull,  unless  it  be  by  an  effusion  of  blood. 

These  effusions  happen  in  rambling  school-boys,  and  are  of 

*  Botallus,  p.  736. 


Of  Injuries  of  the  Scalp.  269 

such  a  description  as  might  tempt  the  inexperienced  surgeon 
to  open  them.  Whether  Irom  opening  such  tumours  any  ill 
consequences  might  result,  I  shall  not  venture  to  predict,  and 
do  not  by  experience  know.  But  of  this  I  am  assured,  that  if 
left  alone  they  are  generally  safe  ;  that  if  the  young  surgeon 
were  to  yield  to  the  suggestions  of  his  own  fear,  whenever  in 
those  cases  he  imagined  he  telt  a  depression,  and  were  upon  this 
presumption  to  cut  open  the  integuments,  and  trepan  the  scull, 
the  issue  of  his  adventure  would  be  very  often  fatal.  The  de- 
ception proceeds  Irom  this  peculiarity,  that  where  the  vessels 
ruptured  by  the  fall  have  made  the  greatest  effusion,  the  blood 
continues  long  fluid  ;  but,  towards  the  margin  of  this  cavity, 
where  the  cellular  substance  is  not  entirely  detached  from  the 
pericranium,  the  blood  is  so  injected  into  the  cellular  substance, 
and  mixed  with  its  fibres,  that  the  basis  and  margin  of  the  tu- 
mour are  uncommonly  firm,  and  the  hardness  such  as  actually 
to  resemble  that  of  bone.  From  this  hard  circumierence,  the 
surface  apparently  declines  towards  that  part  where  the  cranium 
is  more  distinctly  felt  through  the  fluid  blood  ;  and  the  declivity 
is  so  distinct,  and  the  hardness  of  the  margin  so  entirely  re- 
sembles that  of  the  centre,  where  the  scull  is  telt  unequivocally, 
that  the  surgeon  has  not  the  slighttst  doubt  that  he  feels  a  wide 
and  deep  depression  of  the  scull ;  and  when  along  with  this  the 
boy  lies  oppressed,  and  vomiting,  he  can  hardly  refrain  from 
opening  the  tumour,  or  think  himself  vindicated  in  leaving  the 
bov  without  help. 

I  know  no  deception  which  experience  so  effectually  corrects 
as  this,  of  an  apparent  depression  felt  through  a  bloody  tumour 
of  the  scalp  ;  nor  can  any  thing  but  experience  correct  it  ;  lor 
to  the  sense  of  touch,  the  depression  is  so  palpable,  and  the 
boy's  danger  so  very  obvious,  that  even  an  experienced  surgeon, 
on  any  new  occasion  of  examining  such  a  tumour,  is  confused 
with  the  very  peculiar  feeling  ot  that  deception,  which  he  is  al- 
ready aware  of.  Many  times  I  have  been  called  to  rambling 
boys,  who  had  fallen  in  climbing  walls,  or  in  playing  about  saw- 
pits,  and  unfinished  buildings  ;  and  have  often  found  them  with 
great  effusions  of  blood  over  the  parietal  bone,  and  apparent 
depression  ;  the  face  ghastly,  and  the  extremities  cold,  in  a 
state  of  insensibility,  with  the  eyes  not  cldsed,  but  turned  up- 
wards, as  in  the  convulsions  of  children.  But,  fortunately  for 
me,  the  case  of  the  boy  that  I  first  saw  lying  in  this  stupor,  in 
the  earliest  part  of  my  practice,  was  so  perfectly  decisive,  that 
I  have  never  since  been  in  danger  of  any  precipitate  step  ;  for 
this  boy,  who  had  fallen  from  a  garden-wall,  lay  in  a  state  of 
absolute  stupor,  and  with  a  degree  of  convulsion,  during  four 
days.     He  vomited  incessantly,  and  his  extremities  were  cold 


270  Of  Injuries  of  the  Scalp. 

and  his  face  ghastly.  The  appearance  of  depression  was  so 
striking  and  singular,  that  I  made  not  the  slightest  doubt,  that 
if  he  did  recover  without  any  operation,  manifest  marks  ol  de- 
pression must  remain.  But  he  recovered  in  a  lew  days  perfect 
health  and  spirits,  and  the  appearance  of  depression  vanished, 
as  the  blood  was  absorbed.'* 

I  know  not  whether  anv  specific  and  unalterable  rule  can  be 
proposed  lor  the  treatment  of  cases  so  various  in  their  iorms, 
their  causes,  and  probable  effects,  but  something  I  leel  inclined 
to  sav  on  this  subj  ct.  When  the  tumour  assumes  the  proper 
form  of  aneurism, — when  there  is  a  large  and  circumscribed 
tumour,  fluid  blood  in  the  centre, — a  hard  basis  and  margin, — a 
distinct  pulsation  through  the  whole  tumour,  and  its  size  in- 
creasing from  day  to  day,  there  is  great  danger  to  the  scull  : 
the  tumour  should  be  laid  open  without  delay,  and  dressed  with 
lint  ;  and  it  will,  after  two  or  three  days  of  suppuration,  (in 
which  the  matter  will  be  fetid,  from  being  tainted  with  the 
blood),  heal  kindly  ;  for  the  arteries  of  the  scalp,  when  thus 
bruised,  and  pouring  out  blood,  have  sufficient  lorce  to  maintain, 
or  even  to  enlarge,  the  effusion  of  blood  which  cannot  be 
absorbed,  in  opposition  to  such  a  cause.  Yet,  when  opened, 
such  arteries  do  not  bleed  much,  the  hasmorrhagy  is  suppressed 
merely  by  applying  a  bit  of  lint  ;  they  rarely  need  to  be  tied.j 
Lastly,  Effusions  of  blood,  though  unaccompanied  with  pulsa- 
tion, if  they  continue  fluid,  and  do  not  gradually  subside  from 
the  period  of  the  sixth  or  seventh  day,  must  not  be  regarded  as 
of  a  slight  or  indifferent  nature,  and,  before  the  tenth  or  twelfth 
day,  should  be  opened.  From  all  the  experience  I  have  had, 
these  rules  of  conduct  will  be  useful  to  you  ;  and  while  I  warn 
you  to  refrain  in  general  from  opening  such  tumours,  it  is  also 
my  duty  to  state  unequivocally  and  plainly,  that  there  are  others 
which  occasion  caries  of  the  scull,  where  a  little  imprudence,  a 
little  delay,  endangers  the  patient's  life. 

"  Mr.  Harrold,  partner  to  Mr.  Wilmer,  had  a  boy  brought 
to  him,  of  fourteen  years  of  age,  with  a  tumour  on  the  crown  of 

*  Though  the  author's  pradice,  in  this  cafe,  was  fuccefsful,  I  mould  not  be 
difpofed  to  imitate  it.  It  is  certainly  exceedingly  difficult,  in  thefe  cafes,  to  afecr- 
tain  by  the  feel  alone  whether  the  bone  is  depreflcd  or  not,  a  point  of  the  greutelt 
conlequence  to  afcertain  ;  and  as  1  know  by  experience  that  no  injury  rcfults  from 
laying  open  fuch  tumours,  even  though  the  bone  mould  not  be  injured,  I 
mould  recommend  it  in  every  cafe  where  the  tumour  was  confiderable,  or  from 
eireumftances  attending  the  accident,  there  was  reafon  to  apprehend  an  affe&ion 
of  the  fcull.     S. 

f  The  haemorrhages  may  be  retrained  by  a  comprefs,  and  the  bandage  recom- 
mended for  the  head,  (fee  Difcourfe  on  Bandages  p.  30. — 40.)  provided  the  artery 
be  completely  divided,  which  alone  will  be  in  molt  cafes  lufficient.  This  Bandage 
is  particularly  adapted  to  thofe  cafes,  in  which  the  fcalp  has  been  feparated  fr«m 
the  cranium.     S. 


Of  Injuries  of  the  Scalp.  271 

the  head,  the  size  of  a  hen's  egg.  It  was  seated  on  the  middle 
of  the  sagittal  suture  :  it  was  occasioned,  as  his  lather  related, 
by  a  blow,  the  boy  having  been  stiuck  over  the  head  with  the 
arm  of  a  broken  chair  :  the  swelling  ensued  immediately  alter 
the  blow.  The  father  had  flattered  himself  with  hopes  of  its 
dissolving  by  time,  and  the  simple  remedies  recommended  by 
his  neighbours  ;  but  about  two  months  alter  the  blow,  he  brought 
the  boy  to  Mr.  Harrold,  the  tumour  undiminished,  and  con- 
taining, according  to  Mr.  Harrold's  appn  hension,  nothing  but 
blood.  As  a  measure  of  precaution  only,  and  without  appre- 
hending the  disorder  which  had  already  been  produced,  he 
opened  the  tumour  with  a  long  incision,  and  discharged  a  quan- 
tity of  blood,  yet  fluid,  and  not  in  the  slightest  degree  grumuus 
nor  blackened;  and  as  the  artery  from  which  it  had  flowed 
was  still  open,  and  a  considerable  hiemorrhagy  ensued,  he 
dressed  the  cavity  hastily  with  dry  lint. 

"  On  the  second  day,  he  removed  the  external  dressing  ;  but, 
not  chusing  to  risk  a  second  haemorrhagy,  he  left  the  lint  which 
adhered  more  immediately  (and  very  strong!) )  to  the  surfaces, 
untouched  :  when  this  also  was  removed  atnext  dressing,  much 
ichorous  and  putrid  matter  was  discharged,  and, upon  looking  into 
the  bottom  ot  the  cavity,  was  surprised  to  perceive  distinctly  the 
pulsations  of  the  brain,  and  that  the  bone  was  entirely  wanting 
in  all  that  part  which  corresponded  with  the  basis  oithe  tumour, 
a  space  of  two  inches  in  diameter."  The  danger  ot  this  bov, 
then,  was  most  conspicuous  and  imminent ;  fortunately  the  dura 
mater  granulated,  and  the  opening  healed  kindly. 

Such  are  the  dangers  proceeding  lrom  delay,  those  arising 
from  misconduct  are  no  less  to  be  feared* 

"  A  school-boy,  having  his  hair  severely  pulled  in  a  quarrel, 
there  rose  a  small  bloody  tumour  of  the  scalp  which  he  concealed 
for  three  weeks,  till  it  had  extended  lrom  the  size  of  a  pea  to  that 
of  a  large  tumour  seven  inches  long,  and  four  inches  broad, 
rising  very  high  in  its  centre,  and  covering  much  of  the  parietal 
and  Irontal  bone.  This  was  an  aneurism  too  large  to  be  void 
of  danger,  and  required  decision  in  the  opening  ol  it,  and  deli- 
cate dressing  to  prevent  ill  consequences,  and  bring  it  to  a  right 
suppuration.  Mr.  Hill  of  Dumfries  was  desirous  of  having  it 
opened  with  caustic.  The  gentleman  who  had  him  under  his 
care  preferred  the  lancet.  Upon  puncturing  the  tumour,  four 
ounces  of  pure  and  florid  blood  flowed  lrom  it,  and  the  peri- 
cranium appeared  entire.  Mr.  Hill  now  proposed  a  loose  ban- 
dage, till  the  parts  should  have  time  to  contract ;  but  again, 
says  he,  u  I  was  overruled,  and  a  thick  compress  was  bound 
down  over  the  tumour,  and  a  dossil  put  into  the  orifice.  Next 
day,  the  integuments  had  adhered  closely  to  the  pericranium, 


272  Of  Injuries  of  the  Scalp. 

and  a  full  sac  was  formed  at  each  end  ;  and  to  discharge  these, 
the  gentleman  tore  up  the  scalp,  by  thrusting  a  probe  under 
it,  and  then  renewed  the  compress.  On  the  third  day,  the 
sacs  were  again  filled,  the  parts  adhering  so  firmly,  that  the 
probe  could  not  be  introduced,  though  he  tried  it  several  ways, 
and  with  so  much  force,  that  the  bone  was  laid  bare  in  three 
places. 

"  Then  followed  an  oedema  over  all  the  scalp.  The  gentle- 
man to  whose  care  the  case  was  committed  being  out  ot  town, 
the  sore  was  neglected  for  three  days  ;  the  swellings  increased  j 
there  was  much  pain,  fever,  sickness,  and  a  degree  of  delirium 
and  raving.  On  the  fourth,  two  caustics,  notwithstanding  the 
inflamed  state  of  the  scalp,  were  applied  ;  and  on  the  filth,  the 
bloody  and  purulent  matter  being  discharged,  and  a  tomentation 
applied  all  over  the  head,  the  delirium  subsided,  and  the  swell- 
ing soon  vanished.  There  were  now  three  openings,  each  of 
which  continued  to  run  for  many  weeks,  till  the  bones  which 
had  been  laid  bare  exfoliated." 

Before  I  forsake  this  subject  of  injuries  external  to  the  cran- 
ium, I  shall  represent  to  you  one  which  is  attended  with  no 
danger  of  caries,  but  relates  to  the  scalp  only,  a  nervous  and 
most  singular  disease  ;  resembling  that  which  arises  from  some 
injury  in  bleeding  in  the  arm,  attended  with  little  danger,  but 
marked  by  convulsive  motions,  nervous  affections  of  the  most 
undefinable  nature,  and  sometimes  with  agonizing  and  period- 
ical pain  ;  pain  varying  according  to  the  state  of  the  weather, 
or  the  patient's  health. 

"  The  man  whose  case  I  am  going  to  relate  to  you,  was  about 
thirty-two  years  of  age,  sallow,  sickly,  and,  I  fear,  dissolute. 
He  had  lost  his  health,  his  industry,  and  his  morals,  by  an  un- 
fortunate blow  on  the  head,  which  had  deprived  him  of  reason 
for  many  months  ;  and,  after  a  second  blow  on  the  head,  he 
suffered,  in  consequence  of  the  sewing  of  the  temporal  artery, 
a  very  singulaf  nervous  affection. 

"  First,  about  three  years  ago,  he  was  attacked  by  some 
drunken  compnions  of  his  own,  who,  knowing  he  had  in  his 
pocket  thirty  shillings  of  wages,  and  he  refusing  to  treat  them, 
way-laid  him  in  a  dark  passage,  and  knocked  him  down  in  re- 
venge. He  fell  backwards  into  a  cellar-stair,  struck  the  back 
of  his  head  against  the  stones,  and  was  carried  to  the  hospital 
senseless';  where,  notwithstanding  every  care  of  the  surgeons, 
hf-  lo^t  his  reason,  continued  many  months  insane,  left  it  at  last 
in  a  weakly  and  languid  state,  ill  able  to  return  to  his  hard  la- 
bour, that  of  press-man  in  a  printing  office.  From  that  time  he 
wrought  little,  and  irregularly,  became  a  miserable  vagabond, 
subsisting   chiefly    on   charity,  and  living  among  his  friends. 


Of  Injuries  of  the  Scalp.  273 

**  About  three  months  ago,  as  he  was  coming  down  an  open 
stair,  which  had  no  hand-rail,  and  was  so  dangerous  as  to  have 
been  the  occasion  oi  frequent  complaints  to  the  landlord,  he  fell 
over  the  stair,  and  alighted  among  sharp  stones,  and  his  fore- 
head was  laid  open  with  a  ragged  wound,  about  four  inches  in 
length,  extending  from  the  toreheadto  the  temple. 

**  The  stair  was  notoriously  dangerous,  and  the  night  dark, 
but  he  confesses  that  he  was  a  little  tipsy.  Nothing  so  surely  in- 
dicates a  vagabond  and  idle  life,  as  indifference  to  cleanliness  and 
health}  he  did  not  return  to  his  old  asjlum,  the  hospital,  but, 
with  a  penny  worth  of  Wade's  balsam,  and  some  filthy  appara- 
tus of  rags,  made  a  fashion  of  dressing  his  wound,  till,  by  filth 
and  neglect,  it  ulcerated  ;  the  temporal  artery  was  eroded  ;  the 
blood  sprung  briskly  from  the  corner  of  his  sore,  and  thus  he 
was  brought  to  the  infirmary. 

M  The  house-surgeon  sewed  the  artery  ;  he  was  laid  in  bed, 
and  enjoined  not  to  stir,  lest  it  should  burst  out  again.  He  was 
very  timid  by  nature,  and  the  students  took  a  pleasure  in  alarm- 
ing him  from  time  to  time,  with  saying,  that  it  would  surely 
burst  out  again.  About  a  fortnight  after,  the  ulceration  still  ex- 
tending, the  artery  was  again  eroded  ;  and  at  night,  betwixt  ten 
and  eleven  o'clock,  when  turning  gently  in  bed,  he  felt  his  fore- 
head moist:  and,  upon  putting  up  his  hand,  found  it  wet  with 
blood.  The  artery  soon  began  to  bleed  per  saltum  ;  and  the 
house-surgeon  being  called,  the  artery  was  again  secured,  by 
striking  a  needle  and  ligature  under  it. 

u  After  the*  first  sewing  of  the  artery,  he  felt  nothing  unusual ; 
but  after  this  second  stroke  of  the  needle,  he  found,  next  morn- 
ing, his  mouth  pursed  up  and  contracted,  his  jaws  so  clenched 
that  he  could  not  speak,  while  spasmodic  contractions  extended 
along  the  neck  and  throat.  His  cheeks  were  flattened,  and  his 
mouth  pursed  up,  and  at  the  same  time  protruded  as  in  a  ludi- 
crous simper,  or  like  one  attempting  to  whistle,  and  prevented 
by  an  inclination  to  laugh.  The  form  of  the  face  was  remarkably 
changed  ;  the  sphincter  oris  pursed  up  the  mouth,  while  the 
zjgomatic  and  triangular  muscles  retracted  the  corners  of  it, 
and  made  the  dimple  natural  to  that  part  very  deep  ;  the  cheeks 
were  flattened,  the  mouth  protruded ;  when  he  attempted  to 
speak,  which  he  did  imperfectly,  the  whole  face  was  agitated, 
and  his  tongue  got  entangled  between  the  upper  and  lower  ran- 
ges of  teeth,  so  that  he  imagined,  if  he  persisted,  he  might  bite 
it  across  ;  and  the  throat  and  the  whole  neck  was  obviously  con- 
tracted in  a  spasmodic  state,  accompanied  with  remarkable  pain  ; 
and  he  could  not  open  his  jaws  to  receive  the  smallest  particle 
of  food,  but  lived  on  spoon-meat." 

2  M 


l27±  Of  Separation  of  the  Dura  Mater. 

Having  pointed  out  with  deliberation,  and,  I  hope,  with  pre- 
cision and  clearness,  the  various  injuries  of  the  scalp,  I  hasten 
now  to  a  subject  more  interesting  in  an  infinite  degree  ;  I  mean, 
the  consequences  resulting  from  a  separation  of  the  dura  mater 
from  the  internal  surface  of  the  scull. 

SECTION    III. 

Of  Separation  of  the  Dura  Mater. 

The  blow  which  detaches  the  dura  mater,  may  at  the  same 
time  injure  the  integuments,  or  affect  the  scull  ;  hence  nothing 
seems  more  difficult  than  to  ascertain  the  simple  consequences 
of  separation  of  the  dura  mater,  unallied  with  injury  of  the  in- 
teguments or  cranium.  Yet  I  hope  I  shall  be  able,  by  a  suite 
of  facts,  to  prove,  that  the  dura  mater  may  be  separated  even 
by  a  shock,  without  any  direct  injury  to  the  scalp,  or  scull,  and 
to  explain  to  you  all  the  varieties  of  this  accident,  and  all  its  re- 
mote and  unforeseen  consequences. 

"  A  little  boy,  of  five  years  of  age,  fell  from  the  first  story 
of  a  stair,  but  alighted  on  his  feet,  and  walked  up  stairs  again, 
saying  that  he  was  not  hurt ;  no  importunities,  questions,  or 
threats  on  the  part  of  his  parents,  could  ever  extort  from  him 
anv  other  answer,  than  that  he  was  not  hurt ;  indeed,  they  had 
little  reason  for  their  anxiety,  the  boy  appearing  to  enjoy,  for 
three  months,  the  most  perfect  health.  But  at  the  end  of  the 
third  month,  he  was  seized  with  a  violent  headach,  accompa- 
nied with  a  puffing  up  of  the  eye-lids,  and  fits  of  vomiting:  and 
when  the  surgeon  was  called,  he  found  the  face  suffused  with  a 
purple  colour,  and  the  boy  deprived  of  speech,  and  able  only  to 
point  with  his  hand  to  the  place  of  the  pain.  He  was  bled  in 
the  arm  without  loss  of  time  ;  he  grew  worse,  and  was,  a  few 
hours  after,  bled  in  the  leg,  but  almost  immediately,  and  before 
the  orifice  was  closed,  he  expired. 

M  Mr.  Casaubon  being  called  to  open  the  bod)7,  found  with- 
out the  cranium  nothing  particular,  except  a  slight  puffiness  of 
the  integuments  ;  but,  on  opening  the  scull,  he  found  an  exten- 
sive abscess  betwixt  the  dura  mater  and  the  inner  surface  of  the 
right  parietal  bone ;  but  neither  within  the  scull,  nor  in  any 
other  part  of  the  body,  was  any  thing  remarkable  observed." 

Here  we  have  presented  for  our  consideration,  in  a  short, 
plain  narrative,  a  suite  of  most  important  facts.  Fir at ,  A  boy 
falls  from  a  great  height  upon  his  feet,  as  it  would  appear,  in 
the  presence  of  his  parents,  but  certainly  upon  his  feet;  and  the 
dura  matter  is  detached,  not  by  a  blow,  which  might  at  once  in- 
jure the  cranium,  and  shake  the  dura  mater  •  it  is  detached  by 


Of  Separation  of  the  Dura  Mater.  275 

the  shock  merely,  without  any  concomitant  injury  of  the  scull. 
Secondly,  The  integuments  being  sound,  the  cranium  unhurt, 
the  parts  not  disposed  to  run  quickly  into  disease,  the  child  con- 
tinues in  perfect  health,  and  when  he  is  suddenly  seized  with 
the  fatal  signs,  there  is  still  no  conspicuous  swelling  of  the  in- 
teguments ;  and,  when  he  dies,  the  cranium  is  found  in  its  na- 
tural state.  Thirdly,  It  is  remarkable,  that  here,  as  in  almost 
every  instance,  the  suppuration  ot  this  membrane  is  slow  and 
insidious  in  its  progress  ;  tor  this  boy  had  continued  three  months 
in  apparent  health  ;  no  sjmptoms  betrayed  the  danger  :  the  pa- 
rents had  dismissed  their  first  anxieties  and  fears  ;  yet  all  the 
while  this  fatal  suppuration  was  ripening.  The  boy,  the  mo- 
ment he  is  seized  with  the  stupor,  is  gone,  past  remedy.  The 
trepan  could  not  then  have  saved  him  ;  the  cause  of  this  sudden 
and  fatal  convulsion  was  discovered  only  alter  death.  Fourthly, 
Though  the  suppuration  was  of  considerable  extent,  (un  absces 
considerable)  it  had  plainly  arisen  from  the  mere  separation  of 
the  dura  mater  ;  for  the  dura  mater  alone  was  affected ;  long 
as  it  had  been  divorced  from  the  cranium,  neither  was  the  cra- 
nium affected  by  this  separation,  nor  the  brain  by  the  disease  of 
the  membrane  which  immediately  surrounds  it  ;  the  separated 
surface  was  alone  purulent.* 

In  one  ot  the  following  states  and  conditions,  the  dura  ma- 
ter alwass  must  be  after  a  violent  separation  from  the  internal 
surface  ot  the  scull :  First,  Either,  the  bone  being  hurt,  (as  ge- 
nerally happens  in  cases  where  it  is  shaken  by  a  blow)  the  du- 
ra mater  cannot  re-unite,  its  surlace  will  suppurate,  and  the  pa- 
tient die,  with  shiverings,  stupor,  and  palsy;  or,  secondly  the 
dura  mater  may  continue  separate,  and  yet  its  surlace  heal,  but 
with  a  disposition  to  form  fungi,  which  betrav  its  unhealthy  condi- 
tion ;  for  the  cranium,  by  pressure  on  its  lower  surface,  be- 
comes carious,  part  of  it  is  absorbed,  the  fungus  begins  to  pro- 
trude through  a  small  circular  opening,  and  the  tatal  sign  of 
pulsation  in  the  tumour,  is  felt,  u  hich  pulsation  is,  indeed,  the 
motion  of  the  brain  :  then  the  opening  enlarges,  the  fungus  in- 
creases, the  brain  is  at  the  same  time  diseased,  and  sometimes 
suppurates,  and  the  patient,  seized  with  stupor,  with  epilepsy, 
sometimes  with  bowlings,  and  the  must  horrible  convulsions, 
expires. 

In  the  German  Ephimerides,  is  to  be  found  a  case  farther 
confirming  this  singular  fact  of  the  separation  of  the  dura  mater 
by  a  general  sho  !< ;  and  that  the  surface  which  remains  de- 

•  This  cafe  proves  how  flow  and  infulious  fuppurations  of  the  dura  mater  are, 
hut  by  no  means  that  this  membrane  can  be  feparated  by  a  (hock  :  the  contrary  I  take 
to  be  the  more  probable  inference  ;  for  hud  it  been  feparated  by  the  accident,  and 
hud  not  rc-united,  fuppnration  muft,  •  think,  have  immediately  taken  place.     S. 


276  Of  Separation  of  the  Dura  Mater. 

tached,  forms  fungi,  and  destroys  the  scull.  M  This  man  was 
about  fifty-one  years  ot  age,  fell  from  his  horse,  and  was  sensi- 
ble ol  a  vioWnt  concussion  of  the  head;  a  distressing  pain  en- 
sued, but  it  soon  vanished,  and  the  patient  thought  no  longer 
ot  his  fall,  nor  ot  this  pain.  About  tour  years  aiter,  he  be- 
came conscious  of  a  loss  ot  memory  ;  and  this  malady  increased 
so,  from  day  to  day,  that  he  at  last  forgot  what  he  had  said  or 
done  the  moment  before.  Then  came  cruel  and  incessant  fits 
of  epilepsy.  Those  paroxysms  seemed  for  six  months  to  be 
appeased  by  the  medicines  he  took  ;  but  there  followed  next 
pains  of  the  head,  excruciating,  unremitting,  and  continual, 
which  no  remedy  could  alleviate,  and  which,  in  six  months 
more,  proved  fatal  ;  and  so  dreadful  were  these  pains  which 
affected  the  left  side  ot  his  head,  in  the  form  of  megrim,  that 
the  left  eye  was  convulsively  turned  in  its  socket,  by  the  excess 
of  pain. 

"  On  opening  the  scull,  the  middle  and  fore  part  of  the  right 
parietal  bone  was  carious,  and  destroyed  in  a  space  equal  to  the 
size  of  a  half-crown.  Lesser  spots  of  caries  were  observed  in 
various  parts  of  the  scull-cap,  while  the  left  parietal  was  corrupt- 
ed by  a  tungous  excrescence  from  the  dura  mater,  which  ex- 
tended towards  the  orbit,  and  had  destroyed  also  the  cribriform 
plate  of  the  oethmoid  bone." 

Here  we  see  again  the  sudden  shock  separating  the  dura  ma- 
ter, perhaps  to  a  great  extent  from  the  scull.  The  bone  dv  ing, 
and  tailing  into  general  disease,  by  the  loss  of  its  nourishing 
membrane  ;  and  that  fungus  (which  it  seems  the  peculiar  dis- 
position ot  the  dura  mater  to  produce,  when  healed  apart  from 
the  cranium)  destroying  the  parietal  bone,  making  its  way 
through  the  thin  plate  of  the  oethmoid  bone,  and  causing  death 
before  it  had  growth  sufficient  to  produce  an  external  tumour. 

In  speaking  of  tumours  proceeding  trom  within  the  scull,  I 
have  been  mstnsibh  led  on  to  this  subject,  by  considering  the 
various  consequences  of  this  separation  of  the  dura  mater:  and 
my  object  has  been  to  impress  you  with  just  and  serious  fears 
ot  entering  upon  any  surgical  enterprist,  where  such  tumours 
arise  trom  within  the  scull  The  cases  which  I  have  already 
detailed,  are  not  merely  destined  to  adorn  the  works  of  a  learned 
society,  or  to  be  a  matter  of  stupid  yvonder,  but  to  serve  as  use- 
ful yvarnings  ;  they  arc  forms  of  disease,  horrible,  indeed,  in 
their  conclusion,  but  in  their  beginnings,  hardly  to  be  distin- 
guished from  the  most  trivial  tumours:  and  that  surgeon  is  in 
great  danger  who  does  not,  trom  reason  and  reflection,  (for  ex- 
perience few  can  have  in  such  rare  cases)  iorm  a  decided  opi- 
nion the  moment  such  a  tumour  is  exposed,  who  does  not  re- 
solve, with  a  steadiness  not  to  be  shaken,  "  not  to  touch  it  for 


Of  Separation  of  the  Dura  Mater.  277 

the  world."  The  good  that  can  be  done  is  problematical,  the 
danger  dreadful ;  and  the  surgeon  who  but  allows  himseli  to  con- 
suit  upon  such  a  case,  or  to  hearken  to  the  intreatiesof  a  patient 
weary  ot  existence,  is  in  danger  of  robbing  him  of  life.  The 
disease,  it  must  be  acknowledged,  is  fatal  in  the  course  of  na- 
ture ;  yet,  wherever  an  operation  has  been  attempted,  it  has 
uniformly  accelerated  the  death  ot  the  patient. 

Let  these  facts,  then,  stand  to  you  in  place  of  experience. 
Examine,  with  a  scrupulous  and  jealous  precision,  into  the  his- 
tory of  all  tumours  seated  on  the  head.  Regard,  as  suspicious, 
those  which  are  connected  with  venereal  affections,  with  blows, 
or  tails,  or  concussions  ot  the  head.  Regard,  as  peculiarly  dan. 
girous,  all  tumours  ol  slow  growth,  of  deep  pulsation,  reced- 
ing within  the  cranium,  covered  with  puffy  scalp,  and  causing, 
upon  being  repressed,  not  pain,  but  sickness,  contusion  ot  head, 
convulsions,  and  cremblings  of  the  limbs.  When  the  scull  is 
first  destroyed,  and  the  brain,  or  the  internal  tumour  protrudes, 
a  temporary  rcliet  sometimes  ensues.  Occasional  ease  is  some- 
times procured  by  gentle  pressure,  and  equable  support,  but 
the  event  is  inevitably  fatal  ;  and  frequent  swoonings,  insensi- 
bility, coma,  or  quivering  ot  the  limbs,  an  involuntary  discharge 
of  urine  and  faeces,  delirium,  and  convulsion,  close  the  scene. 
Touch  no  such  tumour,  at  the  peril  of  your  reputation  ;  for,  it 
is  either  a  caries  of  the  cranium,  through  which  the  brain  pro- 
trudes, or  an  aneurism  from  without,  or  a  fungus  from  within, 
which  has  destroyed  the  bone. 

Let  us  now  return  to  reflect  on  one  indisputable  fact,  and  it 
is  this  :  Within  the  proper  structure  of  the  scull,  the  circula- 
tion is  so  vigorous,  and  its  sources  of  blood  so  varied,  that  the 
bone  by  no  means  depends  on  any  one  set  of  vessels  for  nourish- 
ment, nor  even  on  that  which  seems  the  most  essential  to  its 
health,  the  dura  mater.  Almost  the  whole  of  the  dura  mater 
may  be  separated  from  the  internal  surface  of  the  scull,  and  yet 
the  union  be  restored.  We  often,  upon  applying  the  trepan, 
perceive  that  the  oppression  of  the  vital  powers  proceeds  from 
an  effusion  of  blood  under  the  scull,  compressing  the  brain. 
The  blood  is  hooked  out  with  probes,  washed  away  with  mild 
injections;  diluted  by  the  natural  secretions,  and  by  the  puru- 
lent discharge  from  the  suppurating  surfaces  of  the  dura  mater 
and  scull ;  and  the  clotted  blood  being  thus  dissolved  and  dis- 
charged, the  surfaces  unite  again.  We  are  often  persuaded,  by 
the  quantity  of  the  extravasated  blood,  that  it  must  have  co- 
vered the  whole  hemisphere  of  the  brain,  up  to  the  sagittal  su- 
ture. We  sometimes  feel  the  extent  of  the  separation,  by  in- 
troducing the  probe  ;  but  we  seldom  have  so  clear  a  conviction, 
as  in  the  following  case  of  th  :  whole  extent  of  the  dura  mater. 


2  78  Of  Separation  of  the  Dura  Mater. 

of  the  whole  internal  periosteum  of  the  scull  being  detached. 
u  A  young  man,  oi  about  thirty  years  of  age,  was  struck  re- 
peatedly on  the  head  witn  a  crab-stick,  and  with  a  loaded  whip. 
Next  morning,  he  was  found  lying  in  a  state  of  profound  le- 
th.irgy,  and  with  his  right  side  paralysed,  but  without  the  slight- 
est appearance  of  fracture,  or  depression  of  the  scull.  The 
marks  ot  the  blows  being  chiefly  on  the  right  side,  that  side 
(contrary  to  a  well-estabiished  rule)  was  first  trepaned,  and  the 
dura  mater  was  found  disengaged  to  such  an  extent,  as  to  con- 
tain, at  least,  six  or  seven  ounces  of  blood,  betwixt  it  and  the 
scull. 

"  This  first  perforation  gave  him  some  respite,  but  his  friends 
resisted  all  further  attempts  to  relieve  him,  till  four  days  had 
elapsed,  when  there  appeared  no  longer  any  hopes  of  life,  and 
he  was  left  to  die  among  the  surgeon's  hands.  Then  the  left 
parietal  bone  was  trepaned.  The  whole  hemisphere  of  the 
brain  was  seen  to  be  surprisingly  compressed  by  a  thick  black 
cake  of  coagulated  blood,  of  the  consistence  and  colour  of  cur- 
rant-jelly. The  cake  of  blood  extended  actually  from  the  falx, 
or  sagittal  suture,  to  the  bottom  of  the  os  petrosum  ;  in  short, 
from  the  vertex  to  the  base  of  the  scull ;  and  seemed  to  con- 
sist of  the  same  quantity  that  was  discharged  from  the  other 
side,  amounting,  of  course,  to  six  or  seven  ounces  of  blood. 
Although  it  was  not  thought  prudent  to  bring  away  at  once  the 
whole  mass,  yet,  so  much  was  discharged,  that,  upon  speaking 
to  the  patient,  he  instantly  looked  up,  like  one  awakened  from 
sleep,  named  every  one,  and  raised  the  arm,  which  had  been 
paralytic,  over  his  head;  and  much  of  the  coagulum  being  re- 
moved, he  recovered  apace,  so  as  to  be  able,  by  the  fifteenth, 
to  walk  into  an  adjoining  room ;  but  by  the  accidental  bursting 
out  of  an  artery  in  the  scalp,  he  was  weakened,  the  confusion 
of  head,  and  even  the  paral)sis,  in  some  degree,  returned. 

**  Some  days  after  this,  his  friends,  despairing  of  his  life, 
laid  him  on  a  litter,  and,  without  acquainting  his  surgeons, 
(Mr.  Hill,  and  Dr.  Gilchrist,  of  Dumfries,)  carried  him  home, 
a  jmrney  of  eight  miles.  The  leftside  ot  the  brain  suppurated 
five  or  six  times,  each  parox\  sm  of  inflammation  being  accom- 
panied with  fever,  stupor,  and  difficult  deglutition,  and  relieved 
by  an  eruption  ot  matter;  and  it  was  remarked,  that  when  such 
suppuration  formed  towards  the  fore  part  of  the  brain,  the 
candle  appeared  to  the  patient  double ;  but  when  the  suppura- 
tion was  backwards,  the  light  appeared  to  have  a  halos,  or 
circle,  round  it ;  and  after  each  eruption  of  matter,  the  candle 
appeared  single  and  distinct.  Notwithstanding  these  occasional 
interruptions,  he  was,  in  three  months,  completely  cured  ;  be- 
came the  father  of  a  family,  and  lived  long  in  perfect  health, 


Of  Separation  of  the  Dura  Mater.  279 

excepting  a  slight   defect  of  memory,    and  slight  convulsive 
twitches,  to  which  he  continued  subject." 

In  this  most  interesting  case,  related  by  Mr.  Hill,  he  had 
taken  every  pains  to  ascertain  the  extent  of  the  separation.  He 
found  no  apology  for  introducing  his  probe  under  the  scull,  on 
the  right  side,  because  the  blood  flowed  freely  out  ;  but,  on  the 
left  side,  his  probe,  while  hooking  out  the  coagulated  blood, 
passed  from  the  trepan-hole,  in  the  centre  of  the  parietal,  down- 
wards, along  the  temporal  bone,  till  it  was  stopptd  bv  the  cur- 
vature of  the  ospetrosum,  and  upwards  again  b\  the  Iambdoidal 
suture,  all  along  the  sagittal  suture,  and  over  the  orbit,  along  the 
frontal  bone;  "  and  it  is  my  persuasion,"  (says  Mr.  Hill,  M  that 
the  separation  of  the  dura  mater  was  not  less  extensive  over  the 
right  side." 

What,  then,  are  we  to  infer  from  these  phenomena  ?  Surelv 
this  :  That,   as  lacerated  scalp  adheres  readily  with  the  external 
surface,  the  dura  mater  has  an  equal    aptitude  to  re-unite  with 
the  internal  surface  of  the  scull  :  and  these  phenomena  present 
themselves  daily  to  the  observation  of  the  practical  surgeon.     He 
presumes,  from  the  sudden  oppression  of  his  patient's    senses, 
and  the  palsy  of  his  limbs,  that  the  dura  mater  is  separated,  by  a 
shock,  or  blow,  not  slightly,  so  as  merely  to  endanger  suppuration, 
but  to  such  extent  as  to  cause  a  great  effusion  of  blood  from  all  its 
vessels.      He  trepans  the  scull,  and  by  the  general  pressure,  and 
rising  of  the   brain,  the   blood  is,  (as  I  have  generally  observed 
it)   spued  up    in  grumous  clots,   through  the  trepan-hole.      He 
puts  in   his    finger, — turns  it  round, — feels  no  solid  resistance, 
and  is  conscious  that  the  dura  mater  is  much  depressed,  and  the 
effusion  of  great  extent.     Sometimes  he  finds  a  cake  of  solid  and 
firm  coagulum,  which  bears  the  pressure  of  tlu  finger.-    At  i  ach 
dressing,  he  introduces  his  probe,  binds  it,  and  turns  it  in  eve  re- 
direction ;  by  injections  of  tepid   water, — by  the  the  help  of  the 
probe, — by  the  purulent  secretion  from  the  surface  of  the  scull, 
and  dura  mater,  the  blood  is  gradually  discharged,  and  bv  eve  re- 
mark it  is  certain,  that  the  extravasation  has  exuded  under  the 
whole  of  one  parietal   bone,  from  the  forehead  to  the  occiput, 
and  sometimes  from  ear  to  ear.     Yet,  by  the  secretion  of  pus, 
and  by  the  heaving  of  the  brain,  the  blood  is  entirely  discharged, 
and  purgc-d  away.     The  scull  and  dura  mater  are  in  a  state  of 
suppuration  by   the  time   they  are  allowed  to   approach  each 
other.     The  dura   mater  is  covered  with  a  velvet-like  pile  of 
granulation.     The  margins  of  the  trepan-hole,  and  (by  inference) 
the  internal  surface  of  the  scull,  is  covered  with  a  similar  pile 
of  granulating  flesh.     The  dura  mater  is,  by  the  pressure  of  the 
brain,  supported  in  close  contact  with  the  scull,  and  the  surfa- 
ces are  unitid,  and  the  trepan-hole  closed  by  a  process  of  nature, 


289  OfContusio  Cruiin. 

visible  to  the  surgeon,  in  every  stage,  and  expressly  resembling 
the  re-union  of  soft  parts. 

SECTION    IV. 

Of  Contmio  Cranii. 

As  it  is  my  wish  that  you  should  on  this,  as  on  all  questions 
of  practice,  draw  your  own  conclusions  from  fair  descriptions 
and  plain  facts,  instead  of  defining  the  essential  change  produ- 
ced in  the  injured  part  of  the  cranium  by  a  blow  or  contusion,  I 
shall  proceed  to  shew  their  effects. 

"  A  man  (says  Dcssault)  of  five  and  thirty  years  of  age,  was 
struck  with  a  bludgeon  over  the  head,  a  blow  which  stunned 
him  for  a  few  minutes,  but  did  not  knock  him  down.  He  had 
himself  bled  in  the  foot,  drank  of  a  vulnerary  potion,  believed 
himself  cured,  and  continued  well  for  a  month.  Then  he  sick- 
ened, lost  his  appetite,  his  tongue  took  on  a  yellow  scurf,  shiv- 
erings  came  on,  he  fell  into  coma,  and  died  on  the  sixth  day. 

"  On  dissection,  (says  Dessault)  we  found  not  the  slightest 
outward  mark  of  injury  ;  the  scalp  was  sound,  the  external  ta- 
ble of  the  scull  had  its  natural  colour,  but  the  internal  table  was 
blackened  through  the  whole  extent  of  the  parietal  bone.  The 
dura  mater  lining  this  part  of  the  scull  was  of  a  colour  still  dark- 
er ;  yet  it  adhered  as  firmly  to  this  surface,  as  to  that  of  the 
uninjured  part  of  the  scull,  while  all  the  lower  surface  of  the 
dura  mater  was  coated  with  an  ash-coloured  viscid  pus,  which 
not  only  covered  the  surface,  and  entered  among  the  convolu- 
tions of  the  brain,  but  tainted  its  substance  to  the  depth  of  seve- 
ral lines.     The  rest  of  the  brain  was  sound  and  natural." 

There  cannot  be  imagined  a  more  perfect  example,  or  short- 
er description  of  contusion,  pure  and  uncomplicated.  The  in- 
teguments still  entire,  without  even  the  slightest  tumour,  so 
that  the  bone  had  not  suffered  by  any  disease  from  without;  the 
dura  mater  still  adhering,  so  that,  unless  the  bone  had  been 
de  dened  by  the  blow,  it  might  have  preserved  its  circulation 
from  within  ;  the  bone  alone  had  been  injured  by  the  blow,  so 
as  to  affect,  in  its  turn,  the  dura  mater,  which  alone  was  infla- 
med and  purulent,  in  consequence  of  the  death  of  those  parts. - 
But  yet  an  accidental  description  of  Le  Dran  pleases  me  still 
more.  "  A  man,  who  had  been  wounded  with  a  sword,  conti- 
nued well,  and  walking  about  in  the  hall  of  the  hospital,  till  the 
seventeenth  dav,  in  the  evening  of  which  day  he  was  suddenly 
seized  with  delirium  and  fever,  and  soon  after  died.  The  first 
table  of  the  scull  was  divided  by  the  sword,  the  second  was  only 
contused  ;  betwixt  the  pericranium  and  scull  was  a  coat  of  a 
sort  of  purulent  mucilage;  the  same  purulent  mucus  was  lodged 


Of  Contusio  Cranii.  281 

betwixt  the  cranium  and  dura  mater,  and  also  betwixt  the  dura 
mater  and  pia  mater. 

"■  When  I  examined  the  cranium,  (says  Le  Dran)  I  disco- 
vered the-  cause  of  this  disordi  r.  There  was  no  fracture  ;  but 
a  contusion,  about  the  bigness  of  a  crown,  was  visible  in  the  di- 
pioc,  discoverable  by  a  large  black  spot,  which  was  of  an  ellip- 
tical figure,  in  a  line  with  the  cut  in  the  external  table,  and  sur- 
rounded by  several  back  ra\s.  I  have  preserved  that  piece  of 
bone  :  and,  although  it  is  dry,  and  I  have  had  it  for  sometime, 
the  black  spot  still  appears  upon  the  internal  table,  and  not  upon 
the  i  xternal  ;  but  it  is  more  conspicuous  against  the  bght." 

But  of  all  the  examples  of  contusio  cranii,  that  produced  by 
the  grazing  of  an  oblique  ball,  or  the  obtuse  blow  of  a  ball, 
whose  force  is  spent,  seems  to  me  the  most  simple  ;  no  other 
kind  of  violence  so  effectually  deadens  a  bone,  nor  so  certainly 
draws  after  it  fatal  consequences.  M  A  Lieutenant  of  the  regi- 
ment of  Havnault,  (sa\  s  Mr.  Martiniere)  was  wounded  with 
a  spent  ball  a  little  above  the  right  frontal  sinus.  The  surgeon 
who  first  saw  him  thought  it  right  to  make  a  crucial  incision, 
to  displav  the  state  oi  the  bone,  which  he  lound  free  from  frac- 
ture or  fissure.  The  ball  had  somewhat  stunned  the  patient, 
but  bleeding  had  relieved  this  s\  mptom  ;  and  there  seemed  to 
be  nothing  to  do  but  take  cart  of  the  wound.  But  at  the  end 
of  three  weeks,  the  patient  fell  into  a  lethargy,  with  a  hard  and 
oppressed  pulse.  When  Mess.  Petit  and  Martiniere  were 
called,  they  found  his  case  desperate;  jet  they  felt  it  to  be 
their  dutv  to  apply  the  trepan.  The  perforalion  gave  vent  to 
a  great  profusion  of  pus  ;  but,  by  being  late  perlormed,  it  was  of 
no  avail." 

I  need  not  seek  to  impose  upon  vou  the  authority  of  respect- 
ed names,  to  confirm  a  theory  which  I  have  proved  ;  but  re- 
mark it  rather  as  a  proof  of  the  ing  nuity  and  good  sense  of 
Botallus,  that  he  understood  so  well  the  invariable  effect  of  a 
ball,  in  deadening  the  bone.  He  regards  even  gun-shot  wound 
of  the  head,  (that  where  there  is  merely  a  bruise,  as  well  as  that 
where  there  is  a  fra<  ture),  as  an  accident  requiring  the  trepan. 
He  represents  the  slightest  touch  of  a  ball  as  a  kind  of  contu- 
sion, never  to  be  neglected.  He  directs,  that  the  piece  so 
struck  should  be  cutout  with  the  trepan.  He  sa\  s,  finally,  that 
having  seen  some  die,  from  such  slight  grazing  ot  a  ball  ne- 
glected, he  has,  invariably,  found  pus  collected  under  the  dura 
mater,  directly  under  the  injured  part  of  the  scull. 

The  soldier  who  is  struck  obliquely  by  a  musket-ball,  whirls 
round,  and  falls.  He  lies  as  in  a  swoon.  When  he  n  vives, 
he  is  cold,  pale,  with  a  haggard  countenance,  and  wild  and  con- 

2N 


2B2  Of  Contusio  Cranii. 

fused  air  ;  but  he  is  soon  able  to  get  upon  his  feet.  He  is  car- 
ried to  a  safe  place  ;  there  is  found  no  external  wound  ;  the  in- 
teguments are  livid,  \et  no  inexperienced  person  would  appre- 
hend any  danger  ;  but  he  continues  pale,  dispirited,  and  lan- 
guid ;  in  a  Jew  days,  the  part  is  puffed  up,  and  slightly  swell- 
ed. He  has  then  sickness,  swimming  in  the  head,  cold  shiver- 
ings,  and  nervous  tremours;  and,  upon  making  an  incision  into 
the  part,  the  bone  is  found  bare,  and  often  discoloured  ;  and  if, 
upon  the  exacerbation  of  these  svmptoms,  the  trepan  is  applied, 
pus  issues  through  the  trepan-hole,  and  the  patient  is  thus 
saved. 

We  cannot  then  but  be  struck  with  all  the  phenomena  of  con- 
tusion, and  take  an  interest  in  them,  for  they  are  far  from  being 
rare;  and  especially,  we  must  be  struck  with  the  apparent 
slightness  of  the  injury,  a  superficial  wound,  unattended,  du- 
ring many  days,  with  either  pain  or  sickness,  or  any  sign  of 
danger.  We  cannot  but  reflect  seriously  on  the  critical  condi- 
tion of  such  a  patient ;  the  slight  variations  which  mark  the 
change  from  health  to  the  most  dangerous  condition  ;  and  above 
all,  on  the  limited  period  in  which  it  is  permitted  us  to  inter- 
pose successfully  ;  how  precious  the  moments  of  reflection  and 
consultation  should  appear ;  how  vigilantly  the  surgeon  should 
watch  over  his  patient,  and  mark  those  changes  of  the  counte- 
nance, that  expression  of  the  eye,  that  mixed  state  of  irritation 
and  languor,  those  alternations  of  delirium  and  reason,  those 
perturbed  nights  and  alarming  dreams,  which  no  nurse  nor  hired 
attendant  is  qualified  to  report :  and  it  is  worthy  of  notice,  that 
the  matter  of  a  suppurated  dura  mater  is  peculiarly  ripe,  i.  e. 
yellow,  viscid,  and  tenacious,  (which  is  to  be  ascribed,  not  to 
the  peculiar  nature  of  those  surfaces,  but  to  the  compressed 
state  of  those  parts,  and  to  the  continual  absorption  of  the  humid 
fluids),  from  the  moment  in  which  such  abscess  is  begun.  And 
let  us  not  forget,  that  it  is  but  the  uncertainty  of  the  signs  that 
suspends  our  resolutions,  for  this  is  an  abscess  which  cannot 
like  any  other,  burst  outwardly  ;  which,  when  once  begun,  pene- 
trates rapidly  to  the  brain,  the  most  susceptible,  and  the  most 
important  organ ;  so  that  there  is  but  a  moment  in  which  the  pa- 
tient can  be  saved. 

To  watch  the  patient,  and  distinguish  the  signs,  so  as  to  in- 
terpose with  decision,  void  of  rashness,  and  seize  the  short  in- 
terval that  is  allowed  us,  is  the  mark  of  professional  skill.*  The 

•  Undoubtedly  a  carious  bone  may,  in  any  part  of  the  body,  remain  infulated, 
furrounded  by  a  fiftulous  and  callous  fore,  but  no  where  is  this  condition  attended 
•with  much  imminent  peril  and  danger,  as  in  the  caries  of  the  fcull.  That  a  contu- 
fed  and  deadened  part  of  the  fcull  fhould  remain  thus  unoffending,  and  unaccom- 
panied with  fymptoms,  is  nothing  but  what  our  philofophy  can  eafily  explain;  it 


m 


Of  Contusio  Cranii.  283 

true  and  lively  manner  in  which  Fallopius  describes  the  mark  for 
discovering  contusion,  and  claims  it  as  his  own,  will  strike  you 
very  much.  "  Since,"  says  he,  "  the  contusion  of  the  bone  is 
very  dangerous,  how,  say  the  commentators,  shall  it  be  known? 
not  by  the  senses,  not  immediately  alter  the  fall,  not  till  the 
third  or  fourth  day."  It  is  to  be  known,  (says  Vidius),  by  mak- 
ing an  incision, — by  the  blackness  of  the  bone.  God  have  mer- 
cy on  those,  whose  physicians  think  fit  to  wait  the  blackening  of 
the  bone.  Why,  bones  the  most  cruelly  mangled  and  depres- 
sed, contused,  as  they  certainly  must  be,  do  not  blacken,  if 
treated  with  prudence  and  care  ;  often,  indeed,  in  wounds,  the 
bone  blackens,  but  that  is  through  length  of  time ;  how,  then, 
shall  we  presently  know,  when  a  bone  is  contused  ?  I  have  not 
heard  nor  read  in  any  writer  the  secret  marks  of  contusion ;  but 
they  are  as  follow : 

u  Look  to  your  nails  ;  remark  their  fresh  and  lively  colour, 
white,  tempered  with  red,  but  spotted  with  specks  ol  a  deader 
white.  Those  spots  have  been  named  by  the  Greeks  nebulae,  by 
us  mendacia ;  and  exactly  such  spots  appear  in  contused  bone, 
red  at  first,  but  afterwards  of  this  dead  white;  for  the  bone 
changes  colour  in  its  various  states  of  life,  death,  and  putridity. 
The  colour  of  a  living  bone  is  white,  delicately  tinged  with  red  ; 
that  of  a  dead  bone,  unmixed  white ;  that  of  a  putrid  or  carious 
bone,  livid  or  black.  This  is  the  cause  why,  when  you  first  lay 
open  a  bone,  you  find  it  of  a  reddish  white  colour;  white,  be- 
cause its  earth  is  of  the  purest;  and  mixed  with  red,  because  it 
contains  the  finer  part  of  the  blood,  a  sort  of  sanguineous  vapour, 
which,  as  it  is  from  the  blood,  is  red.  And  this  is  my  proof, 
and  you  may  witness  it,  that  when  I  scrape  the  cranium,  I  have 
scarcely  penetrated  the  surface,  when  blood  begins  to  flow  ;  and 
so  it  is,  indeed,  in  every  bone. 

"  This  being  established,  it  follows,  that  during  the  first  stage, 
i.  e.  during  the  two  first  days  of  a  contusion,  that  part  which  is 
marked  with  these  specks  of  blood  is  still  alive.  But  the  blood 
exhales  by  the  third  day  ;  for  then  the  contused  parts  are  di- 
vorced, though  without  any  visible  separation  from  the  living 
bone.  They  no  longer  hold  a  living  connection  with  it,  nor  are 
nourished  by  a  circulation  of  humours  ;  hence  the  redness  cea- 
ses, and  the  spots  and  specks  become  white,  which  is  truly  the 
colour  of  a  dead  bone.  Thus  do  I  recognize  contusion  by  the 
change  of  colour ;  I  recognize  it  also  by  its  blackness ;   but  this 

implies  no  more  than  that  the  dura  mater,  if  it  efcape  the  firft  (hock,  may  fecede 
fo  flowly  from  the  deadened  bone,  as  to  lefftn  the  danger  ;  in  fliort,  that  a  contu- 
fion  of  the  fcull  may  terminate  in  mere  caries.  But  this  is  no  realon  why  we 
fhould  depart  from  that  juft  and  important  rule  of  the  ancients,  that  we  feouJd  m 
•all  cafes  of  contufion,  operate  early. 


284  Of  Contwiio  Cranii. 

is  a  mark  too  decisive,  and   too  certainlv  fatal,  to  be   waited 
for.1' 

But  as  yet,  I  have  related  no  fact,  nor  advanced  any  thing, 
which  might  lead  you  to  conceive  thtr  notion  of  an  injury  affect- 
ing  a  part  onlv  of  the  system  of  a  bone,  of  a  caries  of  one  only 
of  the  tables,  and  of  an  abscess  of  the  diploe  which  lies  betwixt 
them.  It  was  what  I  myself  never  suspected  ;  so  that  the  oc- 
casion in  which  I  first  observed  it  was  extremely  interesting. 

**  A  young  man,  in  the  prime  of  life  and  health,  fell  from  his 
cart,  and  the  wheel,  passing  obliquely  over  his  head,  slick  d 
upon  his  scull  as  upon  a  stone.  1  he  integuments  were  torn 
down  to  a  great  extent.  There  were  three  large  and  triangular 
flaps  of  scalp  so  ingrained  with  mud  and  sand,  that  the  blood, 
hair,  integuments,  and  scull,  seemed  caked  into  one  mass  of 
filth.  The  man  was  profoundly  drunk  ;  upon  cleaning  the  flaps 
of  the  scalp,  with  the  design  of  replacing  them,  the  marks  of  the 
cart-wheel  upon  the  scull,  which  was  rough  and  scratched,  were 
so  visible,  as  to  preclude  all  rational  hope  s  ot  re- union  ;  yet  the 
flaps  were  nicely  cleaned,  replaced,  and  held  together  with 
slight  stitches. 

"  That  integuments  so  lacerated,  and  a  scull  so  plainly  inju- 
red, should  recover,  was  not  to  be  looked  for  ;  but  the  injured 
bone  might  exfoliate,  as  a  mere  caries,  and  the  violence,  besides, 
was  of  a  peculiar  kind,  there  was  no  fracture  ;  the  patient  had 
received  no  blow  by  which  the  bone  might  be  contused  through- 
out ;  the  injury  was  apparent  on  the  surface  only,  and  was  pro- 
bably limited  to  the  external  table  of  the  scull.  The  external 
table  might  exfoliate,  but  it  was  infinitely  more  probable,  that 
the  caries  should  penetrate  and  affect  the  dura  mater;  and  it  was 
our  duty  to  watch  for  signs  of  danger ;  and  yet  to  trust  to  nature 
so  long,  as  the  injurv  seemed  local,  so  long  as  it  was  possible 
that  it  might  exfoliate  superficiallv,  and  as  a  mere  caries. 

tkThe  man,  more  astonished  than  hurt,  was  no  sooner  resto- 
red from  his  brutal  state  of  intoxication,  than  he  appeand  to  be 
in  perfect  health  ;  there  were  no  shiverings,  no  fever,  no  con- 
fusion of  head  during  the  day,  nor  delirium  during  the  night; 
much  as  we  were  persuaded  of  his  danger,  it  was  only  danger  to 
be  apprehended,  no  s\  mp'om  as  \et  announced  it.  The  sup- 
puration from  the  integuments  in  such  a  case  is  profuse  and 
foul ;  and,  while  such  a  lacerated  wound,  so  ingrained  with  filth, 
is  cleansing  and  granulating,  it  visibh  mends,  and  the  surgeon 
is  too  apt  to  indulge  hopes,  which  are  never  to  be  realized.  In 
this  case,  the  integuments  first  thickened,  as  they  always  do,  by 
infl  .mmation  ;  were  next  wasted  by  suppuration,  and  remain- 
ing still  insulated,  the  edges  became  livid,  and  sloughed  off*, 
while  the  scull  blackened  more  extensively  ;  a  slight  fever  was 


Of  Contusio  Cranii.  285 

inseparable  from  such  a  state  ;  his  face  was  full,  and  his  eye 
heavy  and  languid  ;  yet  that  was  not  much  to  alarm  us  ;  but  he 
sickened  ;  on  the  thirteenth,  he  was  reported  delirious  during 
the  night.  We  could  no  longer  be  responsible  tor  delav,  and 
he  was  trepaned  ;  and  circumstances  of  the  most  singular  na- 
ture, whkh  I  wrote  down,  (as  always  1  have  done  by  the  bed- 
side of  my  patient),  persuaded  me  on  the  instant  that  this  was  as 
truly  an  abscess  in  the  substance,  in  the  cancellated  part  ot  the 
bone,  as  ever  a  boil  was  an  abscess  ol  the  cellular  substance  of 
the  skin." 

Remarks  in  the  time  of  operation,  and  after  it. 


u  The  integuments,  by  retraction,  by  suppuration,  and  most 
of  all,  by  the  gangn.  ne  or  sloughing  of  the  edges  and  angl  s  of 
the  several  flaps,  were  so  wasted  as  to  have  Kit  an  extent  oi  na- 
ki  d  bone,  as  broad  almost  as  the  palm  of  the  hand.  The  bone 
dry,  and  scabrous,  was  black  in  two  places.  The  perioration 
was  made  near  the  centre  of  the  parietal  bone,  on  a  point  of 
bone  black  as  a  coal.  In  perforating  the  outer  table  of  the  scull, 
not  the  slightest  tint  of  blood  appeared  ;  it  seemed  dr\  through 
all  its  substance  ;  the  saw-dust  was  black  at  first,  and  became 
white  in  the  progress  ot  sawing,  and  as  dry  as  hair-powder  ;  it 
was  easily  blown  away,  and  the  working  of  the  saw  was  like  the 
cutting  ot  button-moulds  from  a  piece  of  horn.  The  whole 
scull  was  extremely  thick;  the  sawing,  which  was  deliberately 
performed,  was  of  course  extremely  slow  ;  at  last  thick  and 
viscid  pus  spouted  up  round  the  instrument,  and  I  had  no 
doubt,  (although  I  had  before  affirmed  the  dura  matt  rand  brain 
to  be  still  unaffected),  that  there  was  an  abscess  ;  that  the  opera- 
tion was  tortunate,  and  might  eventuallv  save  the  patient's  life. 
But  the  most  accurate  probing  of  the  cir  le  with  the  point  of  a 
quill  did  not  discover  to  us  even  a  single  point  in  which  the  per- 
foration was  complete.  The  inner  table,  to  oar  utter  amaze- 
ment, was  perfectly  entire  :  and  there  appeal  <  d,  tor  a  moment, 
no  other  rational  explanation  of  this  phenomenon,  than  that  the 
inner  table  must  have  been  fractured,  pi  rmitting  the  pus  to 
exude  through  some  oblique  passage,  from  an  abscess  ot  the 
dura  mater,  to  the  cancelli  betwixt  the  tables  of  the  scull. 

u  The  crown  of  the  trepan  was  again  applied,  and,  under  the 
impression  of  there  being  an  abscess  betwixt  the  scull  and  dura 
maur,  it  was  turned  boldly  and  freely,  without  fear  of  wounding 
that  membrane,  when  suddenlv  there  issued  through  the  trepan- 
hole  much  blood  ;  and  it  was  feared,  that  some  ill  accident  had 


286  Of  Contusio  G'ranii. 

happened,  in  short,  that  the  dura  mater  was  wounded.  But, 
upon  probing  with  the  quill,  the  inner  table  was  found  still 
entire  ;  there  was  every  reason  for  sawing  slowly  and  cautiously; 
and  it  was,  accordingly,  very  long  in  cutting  through.  During 
all  this  stage  of  the  operation,  the  blood  flowed  protuseh  ;  and, 
when  the  circle  of  bone  was  at  last  taken  out,  the  blood  and 
matter  ceased  to  flow.  The  dura  mater  was  seen  white  and 
clean,  firmly  attached  to  the  edg-.s  of  the  bony  circle,  and  no 
where  suppurated  ;  and  every  circumstance  of  the  operation  in- 
clined me  to  examine  the  trepaned  circle  with  particular  ac- 
curacy. 

u  The  circle  of  bone  sawed  out  with  the  trephine  was,  except 
one,  the  thickest  I  had  ever  seen.     The  external  surlace  was 
perfectly  black  ;  the  hole  where  the  centre- tooth  of  the  trepan 
pierced  this  carious  table,   and  all  the  sides  of  the  same  table, 
were  of  a  dead,  white,  or  ash  colour  ;  the  cancelli  were  gaping 
and  irregular,  yet  without  any  very  particular  appearance.     But 
the  inner  table  was  red  in  its  substance,  and  bloody  in  its  edges. 
u  The  state  of  the  dura  mater  was,  during  the  cure,  the  sub- 
ject of  my  most  careful  investigation.     There  was,  I  am  well 
assured,  no  abscess  ;  its  surface  changed,  and  it  went  through 
the  process  of  granulating  without  more  matter  than  that  which 
that  process  implies,  and  such  as  the  exposed  surface   alone 
might  produce.     These  descriptions,  taken  carefully  from  my 
case-book,  require  no  comment.     This  at  least  is  sure,  that  the 
inner  table  may  remain  sound,  and  full  of  blood,  while  the  exter- 
nal table  and  cancelli  are  contused  and  dead  ;  and  I  have  no 
doubt,  that  this  man  was  saved  from  most  imminent  danger. 
Every  such  caries  should  be  trepaned  ;  very  slight  indeed  is 
the  chance  of  such  an  injury  being  partial  at  the  first,  or  conti- 
nuing so  ;  still  less  likely  is  it,  that  after  penetrating  just  to  the 
dura  mater,  it  should  be  separated  by  an  effort  of  nature." 

The  following  interesting  case,  communicated  to  me  by  my 
able  and  much-esteemed  friend,  Professor  Jeffrey,  and  related 
by  his  nephew  Mr.  M'Dougall,  who  attended  the  patient  in  her 
last  moments,  will,  I  believe,  be  highly  gratifying  to  you. 

a  A  young  woman,  living  then  in  London,  about  six  and 
twenty  years  of  age,  was  struck  down  by  a  smoothing-iron  fal- 
ling from  a  height,  where  it  had  been  carelessly  hung,  perpendi- 
cularly upon  her  head.  It  struck  her  on  the  top  of  the  head,  on 
the  upper  part  of  the  left  parietal  bone.  She  was  conveyed  to 
an  hospital  in  a  state  of  insensibility,  and  continued  delirious 
for  some  time.  She  was  bled,  the  head  shaved,  the  wound  in 
the  scalp  enlarged  ;  and  when  she  recovered  her  senses,  she 
complained  of  a  sense  of  giddiness,  accompanied  with  pain  of 
the  head,  which  continued  for  many  weeks.     Of  the  state  of 


OfContusio  Cranii.  287 

the  bone  she  had  never  been  distinctly  informed,  but  could  per- 
ceive at  the  end  of  some  months,  that  the  surgeon,  or  his  assist- 
ant, at  each  dressing,  attempted  to  extract  a  large  piece  of  dead 
bone,  which  was  moveable,  and  which  they  shook  and  pulled  in 
various  directions.  During  these  attempts,  the  sore  was  dres- 
sed with  lint,  and  a  poultice  was  occasionally  applied. 

"  She  remained  very  long  in  the  hospital,  (^ight  or  nme 
months),  where  her  health  having  suffered  greatly,  the  physician 
suggested  to  her  the  propriety  of  removing  to  the  country.  She 
complied  with  this  advice  ;  and  after  three  or  four  months  spent 
with  her  friends,  she  returned  to  the  hospital  much  recruiu  d. 
Many  and  various  attempts  were  now  made  to  disengage  the 
insulated  piece  of  bone.  Her  health  began  again  to  decline,  her 
appetite  failed,  she  was  greatly  reduced  by  fever,  fits,  and  pro- 
fuse perspirations.  The  discharge  Irom  the  carious  ulcer,  pro- 
fuse as  it  had  always  been,  was  now  greatly  increased,  becom- 
ing more  profuse  and  extremely  fetid,  as  she  became  weaker. 
Nourishing  diet  and  cordials  were  not  spared.  She  felt  that 
her  health  could  not  improve  in  the  air  of  an  hospital  in  London, 
and  resolved  to  return  to  Scotland,  to  live  or  die  among  her 
friends  ;  weak  as  she  was,  she  actually  performed  this  journey 
of  400  miles  in  a  mail-coach. 

u  When  leaving  London,  the  gentlemen  under  whose  care 
she  had  been,  charged  her  never  to  permit  any  operation  for  the 
removing  ol  the  carious  part  of  the  scull.  They  remarked,  that 
the  bone,  which  was  slowly  decaying,  would  be  at  last  disenga- 
ged by  the  ulceration  and  erosion  destroying  those  parts  by  which 
it  was  surrounded  ;  that  to  this  alone  should  she  trust;  the  pro- 
cess ot  nature,  they  said,  was  safe,  and  sure  to  happen,  if  she 
could  but  regain  her  health  ;  the  expedient  which  would  proba- 
blv  be  proposed  to  her,  of  applying  the  trepan,  extremely  dan- 
gerous. 

"  On  her  arriving  in  Glasgow,  and  applving  to  Mr.  Ander- 
son, an  eminent  surgeon  in  that  city,  his  opinion  was  so  entirely 
opposite  to  this,  he  was  so  persuaded  of  the  propriety  of  remov- 
ing this  insulated  bone,  (now  entirely  uncovered,  and  of  great 
extent),  that  he  remonstrated  with  the  patient,  argued  with  her 
friends,  and  assured  all  who  had  an  interest  in  her,  that  the  pain, 
irritation,  diarrhoea,  and  fever,  the  want  of  appetite,  and  pro- 
fuse discharge,  could  not  fail  to  bring  her  soon  to  the  grave: 
But  still  his  advice  was  neglected,  till  at  last  her  health  manifest- 
ly declining,  and  her  situation  being  in  all  respects  hopeless,  the 
operation  was  assented  to. 

"  With  the  design  of  afterwards  bursting  up  the  corrupted 
part  of  the  bone,  he  applied  the  crown  of  a  very  large  trepan 
nearly  on  the  centre  of  this  extensive  caries ;  an  operation  which 


288  OfContusio  Cranii. 

was  not  accomplished  easily,  nor  at  once  ;  for  such  was  the  per- 
verse and  fretful  temper  of  the  patient,  fatigued  with  pain  and 
suffering,  that  she  submitted  very  ill  to  the  operation  ;  such,  in- 
deed, was  her  real  weakness,  that  in  place  of  completing  the 
perforation  at  once,  Mr.  Anderson  thought  it  prudent  to  allow 
two  days  to  elapse  betwixt  the  first  and  second  application  of 
the  trep  >n. 

"  B\  this  central  perforation,  the  insulated  bone  was  convert- 
ed into  a  broad  ring;  it  was  ol  the  form  of  a  quoit  ;  and  a  se- 
cond perforation,  with  a  smaller  crown  of  a  trepan,  would  have 
divided  the  ring,  have  reduced  it  in  the  form  of  a  crescent,  and 
have  enabled  the  operator  to  break  up  and  extract  the  caries, 
without  endangering  the  dura  mater.  But  he  was  not  permitted 
to  complete  his  operation  ;  if  there  was  either  danger  or  pain  in 
the  operation,  he  had  done  all  the  harm,  but  was  permitted  to 
do  none  of  the  g  jod  that  might  have  been  expected.  Though 
prevented  from  Infilling  his  more  important  duties,  he  conti- 
nued his  charitable  visits  to  the  patient.  He  still  hoped,  in 
some  period  of  pain,  or  from  a  deliberate  conviction  of  her  dan- 
ger, that  she  would  allow  him  to  complete  his  operation  ;  but, 
wearied  with  opposition,  and  finding  himself  really  useless,  he 
at  last  withdrew. 

"It  was  from  charitable  motives  onl' ,  to  sooth  and  alleviate 
her  distress,  without  the  slightest  hope  or  design  of  offering  any 
more  important  assistance,  that  Mr.  M'Dougall  now  agreed 
to  attend  her,  and  assist  her  friends  in  applying  the  dressings, 
and  keeping  her  sore  in  the  best  condition.  The  state  ot  mat- 
ter at  this  period  is  excellently  well  represented  in  the  following 
report  by  Mr.  M'Dougall. 

"  On  removing  the  bandage  and  dressings,  I  had  now  an  op- 
portunity of  seeing  the  extent  and  appearance  of  the  disease. 
The  scalp  had  ulcerated  and  sloughed  off  to  the  extent  of  five  or 
six  inches  in  diameter,  exposing  almost  all  the  upper  part  of  the 
scull.  The  insulated  piece  consisted  of  the  upper  and  back  part 
ol  the  right  and  left  parietal  bones.  It  extended  from  the  lamb- 
doid  suture  behind,  to  within  two  inches  of  the  coronal  suture 
before.  The  sagittal  suture  was  seen  to  run  along  the  middle  of 
this  caries,  which  measured  transversely  five  inches,  and  lon- 
gitudinally three  inches  and  a  half.  A  great  part  of  the  exter- 
nal table  of  the  loose  bone  had  mouldered  away,  and  the  dura 
mater  was  seen  through  the  trepan-hole,  and  through  many  ul- 
cerations in  the  scull,  covered  with  pale  unhealthy  granulations. 
The  edges  of  the  scalp  were  swollen,  livid,  and  painful,  and  the 
discharge  of  pus  was  profuse,  of  a  dark  colour,  and  very  fetid. 
The  insulated  piece  of  bone  was  immersed  in  matter,  blackened 
on  its  surface,  and  incrustedwith  the  discharge.     I  could  easily 


Of  Contusio  Cranii.  289 

move  this  piece  of  bone  a  little  way  upwards  or  downwards,  or 
to  either  side,  the  thin  edges  of  it  passing  at  each  movement  un- 
der the  edge,  or  between  the  tables  of  tne  surrounding  bones. 
It  could  even  be  depressed  a  few  degrees,  though  the  resistance 
to  this  was  very  considerable  ;  nor  did  the  patient  com- 
plain of  any  uneasiness.  It  was  this  resistance  that  enabled 
Mr.  Anderson  to  apply  the  trepan  on  the  insulated  piece  of 
bone  itself. 

"  Compresses  had  been  applied  to  prevent  the  matter  from 
descending  betwixt  the  cranium  and  scalp,  but  without  success. 
The  matter  had  worked  its  way  downwards,  forwards  and  back- 
wards, had  destroyed  the  cartilaginous  tube  of  the  external  ear, 
g'ving  a  free  exit  to  the  discharge  through  the  external  meatus, 
and  had  separated  the  scalp  from  the  squamous  portion  of  the 
temporal,  from  almost  the  whole  of  the  left  parietal,  and  from 
a  great  part  of  the  occipital  bone.  The  matter  had  descended 
to  the  neck,  and  formed  a  large  collection  there,  which  poin- 
ted ;  but  the  patient  would  not  allow  of  a  counter-opening. 
The  application  of  compresses,  to  prevent  its  accumulation,  was 
now  out  of  the  question,  for  the  scalp  covering  the  left  and  back 
part  of  the  cranium  had  become  livid,  and  extremely  painful  to 
the  touch,  and  as  thin  as  paper.  A  bent  probe,  when  introdu- 
ced under  the  scalp  directly  backwards,  could  be  passed  down 
to  the  neck,  and  made  to  turn  round  the  convexity  of  the  scull, 
till  it  was  withdrawn  opposite  to  the  ear.  The  bone  felt  rough, 
and  denuded  of  pericranium  throughout  this  whole  circuit.  The 
matter  exuded  also  from  under  the  bones  of  the  cranium,  and 
had  detached  the  dura  mater  from  them  to  a  considerable  extent 
laterally,  and  downwards  to  the  base  of  the  scull. 

"  The  ulcerated  scalp  was  dressed  morning  and  evening 
with  a  pledget  of  lint,  covered  with  soft  ointment.  Tow  was 
applied  above  the  lint,  to  absorb  the  matter,  and  the  whole 
was  retained  by  a  bandage  loosely  applied.  At  each  dressing, 
about  an  English  pint  of  a  dark-coloured  fetid  matter,  very 
much  resembling  coffee-grounds,  could,  with  gentle  pressure, 
be  forced  up  from  the  neck,  and  from  betwixt  the  cranium  and 
scalp  on  the  left  side,  and  discharged  at  the  large  opening  above. 
The  scalp  bled  on  the  slightest  touch,  but  the  blood  was  almost 
without  colour. 

"  The  patient  had  at  this  time  survived  the  accident  twenty- 
three  months.  She  lived  about  a  month  longer,  her  debility 
daily  increasing  till  she  died.* 

*  "  I  need  not,  Sir,  fend  von  a  copy  of  my  notes  of  the  diffection ;  as  nothing 
very  remarkable  prefented  itielf.  I  may  remark,  that  the  dura  mater  adhered 
very  firmly,  where  it  was  connected  with  the  parietal  bones  anteriorly,  and  was 
•n  general  much  thickened  in  its  fubftance.  "   Petkh  M'Do't.u.i." 

2  0 


290  Of  Suppuration  of  the  Brain. 

It  is  my  opinion,  that  the  carious  bone  of  a  member  may  be 
left,  till  it  bt  discharged  or  loosened  by  nature  ;  but  that  when 
a  vital  organ,  as  the-  brain,  is  endangered  by  slow  exfoliation, 
the  bone  should  be  r«  moved  as  soon  as  it  begins  to  shake  ; 
that  life  being  at  stake,  nature,  when  she  makes  the  effort, 
should  be  assisted,  but  alwa\  s  modestly  and  delicately.  There 
are  circumstances,  in  which  it  is  plainly  our  duty,  not  only  by 
shaking  and  moving  the  deciduous  piece,  but  by  cutting  and 
trepaning  the  scull,  to  remove  it ;  for,  when  the  integuments 
ha\e  sloughed  off ;  when  much,  or  the  whole  of  the  cranium 
is  bare ;  when  the  dura  mater  is  ulcerated  over  almost  all  its 
surface  ;  when  one  separated  piece  of  bone  supports  an  ulce- 
ration and  caries  over  a  great  extent  of  the  scull  ;  I  should  (in 
hopes  of  removing  that  insulated  piece  of  bone)  proceed  to 
the  most  dangerous  and  fatiguing  (for  these  are  not  painful) 
operations,  as  freely  as  I  should  pull  a  thorn  out  of  the  flesh. 


section  v. 

Of  Suppuration  of  the  Brain,  from  rvhatsoever  cause  it  proceeds, 
whether  from  Laceration  of  the  InUguments,  Separation  of 
the  Dura  Mater,  or  Contusion  of  the  Scull ;  of  the  Signs  of 
Danger,  and  the  proper  Time  for  Operating. 

You  now  perceive,  that  contusions  of  the  cranium  lead  natu- 
rally to  one  of  two  forms  of  disease  ;  either  to  a  mere  exfoli- 
ation, a  disease  limited  to  the  bone,  and  long  protracted,  yet 
in  no  period  void  of  danger  ;  or  a  present  affection  of  the  dura 
mater  penetrating  in  a  few  days  to  the  brain  itself,  and  follow- 
ed by  vcrv  sudden  death.  If,  in  demonstrating  to  you  the  va- 
rious affections  o!  the  lacerated  scalp,  separated  dura  mater,  and 
contused  bone,  I  have  treated  individually  and  distinctly  of  af- 
fections which  are  oftener  combined,  it  is  with  the  purpose,  first, 
of  proving  that  they  do  happen  independently  of  one  another  ; 
an  1,  secondly,  of  accustoming  you  to  reason  correctly  on  the 
individual  facts  ;  and  teaching  you  to  distinguish  the  peculiar 
constitutions  and  affections  of  each  part,  so  as  to  be  able  to  fore- 
tell the  dangers  resulting  from  t  ach  particular  injury.  But  these 
parts  having  one  common  circulation,  and  a  mutual  sympathy 
and  dc  pendence,  the  blow  which  affects  the  bone,  by  contusion, 
must  necessarily,  in  mostcas*  s,  shake  the  dura  mater,  and  dead- 
en the  integuments,  and  produce,  by  this  complicated  injury, 
symptoms  different  in  complexion  (and  more  immediate  in 
their  consequences)  from  any  I  have  yet  described.  I  have 
now  to  describe  that  form  of  contusion  where  the  symptoms 


Of  Suppuration  of  the  Brain.  291 

immediately  follow  the  injury;  where,  though  there  is  no  ex- 
ternal wound,  nor  apparent  bruise,  to  intimate  the  patient's  dan- 
ger, there  rises,  alter  a  lew  days  of  shiverings,  and  indescriba- 
ble contusion  ot  head,  a  puffy  tumour,  the  surest  mark  of  dan- 
ger, and  where  in  a  few  days  more  the  brain  is  deeply  affected, 
and  the  patient  dies.  I  am  now  to  explain  to  you  the  princi- 
ples on  which  this  case  is  to  be  resolved,  the  rules  and  data,  ac- 
cording to  which  a  consultation,  the  most  solemn  and  interest- 
ing in  cur  profession,  is  to  be  conducted.  The  confusion  of 
head,  shivering,  and  fever,  are  all  too  slight  to  alarm  the  patient 
or  his  friends,  and  his  surgeon  only  can  justly  estimate  his  si- 
tuation. The  symptoms  are  too  slight  to  allow  the  mention  of 
an  operation,  esteemed  the  most  hazardous  in  surgery,  which 
yet  must  be  immediately  performed,  else  the  man  is  lost  without 
redemption.  Not  one  among  you,  perhaps,  is  destined  ever 
once  to  perform  lithotomy,  but  there  is  not  one  of  you  who  will 
not  probably  be  called  upon,  in  future  practice,  to  decide  upon 
the  most  difficult  of  all  questions  respecting  injuries  of  the  head; 
to  deliver  before  a  jury  a  sentence  on  life  or  death  ;  to  proclaim 
the  motives  and  principles  of  your  practice,  your  reputation 
being  involved  in  the  fate  both  of  your  patient,  and  of  the  cri- 
minal accused  of  his  death.  The  phenomena  which  I  have  hi- 
therto described,  are  chiefly  those  of  caries,  affecting  only  the 
bone,  sometimes  protracted  for  months  or  years ;  but  the  train 
of  symptoms  1  am  now  to  describe,  are  those  from  which  dan- 
ger is  inseparable. 

A  man,  in  a  quarrel,  or  in  a  riot,  is  knocked  down  with  a 
brick-bat,  or  bludgeon.  He  is,  perhaps,  only  stunned  by  the 
blow,  and  does  not  fall  down  :  he  is  sickened,  taint,  cold,  and 
pale,  but  in  a  few  minutes  he  feels  quite  recovered  :  oten  a 
blow  apparentlv  more  terrible,  is  harmless :  but  whatever  may 
be  the  force,  there  is  unhappily  no  criterion  ot  the  eff  ct  of  such 
a  blow.  Though  a  patient  thus  hurt  is  apparently  well,  and 
goes  about  his  usual  occupations,  he  feels  a  depression  of  spi- 
rits, and  a  confusion  of  head,  a  want  of  appetite,  and  loathing 
of  food :  he  is  in  a  faint,  languid,  and  nervous  condition :  his 
hands  tremble,  and  his  head  swims  upon  being  hurn.-d  in  I  x- 
ercise,  or  disturbed  with  any  unusual  emotion,  and  h<j  passes 
the  night  in  unquiet  sleep,  and  terrifving  dreams,  trom  which 
he  wakes  in  indescribable  confusion, from  time  to  time.  In  a 
few  days,  the  part  injured,  though  at  first  it  was  hardly  livid, 
rises  into  a  puffy  tumour,  round,  soft,  regular,  circumscribed  ; 
important,  only  as  it  is  connected  with  these  signs  of  danger, 
and  as  it  implies  a  detachment  of  the  dura  mater,  and  contusion 
of  the  bone. 

In  a  few  days,  the  fever  is  more  conspicuous,  (though  per- 


292  Of  Suppuration  of  the  Bruin. 

haps  the  tumour  is  flattened)  with  slight  horrors  and  shiverings ; 
the  contusion  is  more  distressing,  attended  with  pain,  and  a 
sense  of  girding  in  the  head  ;  he  can  no  longer  endure  the  light ; 
the  eyes  are  red,  swollen  and  gummy ;  the  pulse  is  quick  and 
weak  ;  the  tongue  foul ;  the  skin  parched  ;  the  visage  pale  and 
ghastly,  with  a  hectic  flush  upon  the  cheek  ;  the  urine  pale,  and 
sparing  in  quantity  ;  the  hands,  and  the  tongue,  when  he  puts  it 
out,  tremble.  He  knows  not  what  ails  him,  but  is,  night  and 
day,  in  a  state  of  indescribable  confusion.  During  the  night, 
roving,  grinding  the  teeth,  and  slightly  delirious  ;  and  during 
the  day,  desponding,  oppressed  and  sick. 

If  the  surgeon  be  fully  aware  of  the  import  of  these  slight, 
but  alarming  signs,  he  opens  this  puffy  tumour  with  the  scalpel, 
and  finds  the  bone  dry,  and  whitish,  or  inclining  to  yellow. 
He  knows  by  the  aspect  of  the  pores,  which  are  the  holes  by  which 
the  arteries  entered  it,  that  it  is  dead.  He  applies  the  trepan, 
and  upon  taking  out  the  piece,  finds  that  there  is  a  slight  coating 
of  cream-coloured  pus  upon  the  dura  mater,  and  congratulates 
himself,  not  without  reason,  on  having  anticipated  the  danger, 
and  saved  his  patient's  life  ;  for  usually  the  symptoms  subside 
after  perforation,  the  dura  mater  reddens,  granulates,  and  heals 
along  with  the  scalp,  with  which  it  unites  in  one  common  ci- 
catrix.* 

But,  if  the  patient  be  regardless  of  these  symptoms,  uncon- 
scious of  his  situation,  or  indifferent  to  the  intreaties  of  his 
surgeon  ;  if  any  how  this  happy  interval  be  neglected,  the  ulcer, 
which  was  in  this  stage  confined  to  the  dura  mater,  extends 
to  the  brain.  The  confusion  of  head,  and  fever  increase  :  the 
patient  becomes  stupid,  and  drowsy,  and  awakes  from  sleep  in 
great  confusion  and  alarm.  He  has  longer  shiverings,  and 
more  continual  sickness  ;  his  knees  totter  under  him,  his  hands 
tremble,  and  his  face  is  often  slightly  distorted  with  spasms  ; 
and  his  limbs,  especially  of  one  side,  are  often  slightly  con- 
vulsed ;  and  growing  gradually  weaker,  he  sometimes  becomes 
paralytic  of  one  side,  but  usually  becomes  only  more  stupid, 
and  oppressed,  and  suffers  slight  convulsive  paroxysms  before 
he  dies.  During  the  first  eight  or  ten  clays,  he  is  in  this  state 
of  languor  and  sickness  ;  from  the  tenth  to  the  twentieth,  he  is 
in  manifest  danger  ;  and  usually  before  the  twentieth  or  twenty- 
fifth  day,  he  expires. 

The  nature  of  this  puffy  tumour,  and  the  sad  presages  to  be 
drawn  from  it,  are  now  plain  to  you.     The  blow  which  contu- 

*  Although  the  operation  fliould  certainly  be  performed  under  thefc  circum- 
flances,  as  giving  the  only  chancs  for  life,  the  furgfon  fhonld  not  be  too  faneuine 
a$  to  the  evert.     S. 


Of  Suppuration  of  the  Brain.  293 

ses  the  bone,  deadens  the  scalp,  and  that  surface  which  is  next 
the  cranium,  is  chit  fly  affected,  in  consequence  of  the  hard  resis- 
tance of  the  bone:  the  surface  of  the  scalp,  in  contact  with 
the  contused  scull,  is  gangrenous,  and  thence  the  tumour  is  em- 
physematous, soit,  uninttamed :  the  deadened  part  being  lim- 
ited, gives  a  circular  lorm  to  the  tumour  ;  b)  the  extravasation 
of  blood,  and  inflammatory  thickening  ot  the  surrounding  parts, 
it  is  circumscribed  ;  and  by  its  relation  to  the  contusion  01  the 
bone,  and  the  probable  separation  of  the  dura  mater,  such 
tumour  becomes  the  most  infallible  sign  of  danger.  Nor  is  it  to 
be  doubted,  that  such  puffy  tumour  arises  from  the  contusion  of 
the  bone,  and  the  bruising  of  the  scalp  ;  for  the  separation  of 
the  dura  mater  will  not  cause  it.  Often  have  I  seen  the  pa- 
tient, who  had  great  effusions  of  blood  betwixt  the  scull  and 
dura  mater,  lie  for  days  or  weeks  oppressed  and  unassisted; 
but  never  have  I  seen  such  separation  ot  the  dura  mater  marked 
with  puffy  tumour. 

"T.  a  big  gross  man,  of  about  thirty  years  of  age,  was 
(upon  I  know  not  what  quarrel,  but  I  believe  in  defending  a  little 
boy  who  had  been  abused)  knocked  down  with  a  brick  bat. 
The  fellow  who  had  abused  the  boy,  and  then  revenged  himself 
upon  the  innocent  man  who  interposed,  was  notorious  for  his 
savage  dispositions,  and  lor  such  uncommon  bodily  strength, 
as  to  leave  no  apology  lor  his  lifting  any  thing  like  a  weapon. 
He  lifted  half  a  brick,  and,  standing  on  a  stair  to  which  he  had 
retreated,  threw  the  brick  with  all  his  force,  and  hit  T.  on  the 
head  a  blow  which  felled  him  to  the  ground.  He  lay  very  long 
insensible,  for  the  space  of  a  day  and  a  night,  in  his  own  house, 
so  that  had  we  seen  him  at  this  period,  we  might  have  appre- 
hended some  bursting  of  blood-vessels,  and  extravasation 
within  ;  but  he  revived,  recovered  his  senses  entirely,  found 
the  cut  on  his  head  very  trivial,  and  would  have  returned  to  his 
trade,  but  for  that  indescribable  sickness  and  languor  which 
hung  about  him,  without  any  remarkable  symptoms,  to  the  hour 
of  his  death. 

"■  Deep  as  the  ulcer  had  penetrated  into  the  brain,  and  early 
as  the  symptoms  began  in  this  man,  they  were  all  along  very 
slight.  He  had  hardly  recovered  from  the  insensibility,  when 
the  shiverings  commenced.  On  the  3d  day  he  had  frequent 
fits  of  shivering,  ot  a  quarter  ot  an  hour's  duration,  followed  by 
heat  and  thirst.  A  purge  (which  I  prescribed  on  the  4th)  of 
jalap,  and  submuriate  ot  mercury,  operated  smartly,  and  re- 
lieved the  pains  in  his  h«ad.  Next  morning,  I  found  the  ver- 
tigo, head-achs,  and  tinnitus  aurium,  almost  gone,  and  he  felt 
nothing  but  a  degree  of  weakness,  and  languor,  and  disturbed 
sleep.     On  the  6th  day,  I  found  this  giddiness,  languor,  and 


294  Of  Suppuration  of  the  Brain. 

pain,  increased,  but  again  relieved  on  the  Tth,  by  the  operation 
of  a  second  purge  :   and,  on  the  8th,  he  mentioned  but  slightly 
the  pain  of  the  head,  and   seemed  chiefly  distressed  by  the  de- 
bility and  languor.     In  this  state  did  I  watch  him  carefully,  ihe 
headachs     being  relieved,  but  the    languor  increasing,  till   the 
10th  day,  when,  besides  the   oppression    and    languor,  he  felt 
sickness. — an  increase  of  the  headachs, — long-continued  chillness 
and   horrors, — a  degree  of  contusion  during  the  night  ;  and  he 
awakened,  not  as  from  a  refreshing    sleep,  but  oppressed  in  an 
unusual  degree,  with  a  hot  skin,  and  fretful  pulse  ;  and  he  had 
that  dV gree  of  constipation  which  I  know  not  whether  to  ascribe 
in  such  cases,  to  sudden  confinement  after  a  state  of  health,  or 
to  an  incipient  state  of  paralysis,  which  affects  always,  I  observe, 
the  viscera,  before  it  sensibly  affects  the  limbs.     By  a  repetition 
of  the  purge,  his  confusion  of  head,   and  sickly  feelings,  were 
again  abated,  and   something  of  cheerfulness  and  content  was 
visible  in  his  countenance.     He  remonstrated  strongly   against 
the  cutting  of  his  hair,  under  pretext  of  the  ill  effects  which  he 
had  always  experienced  from  cutting  his  hair,  which  infallibly, 
he  said,  produced  headachs  ;  but  really,  I  believe ,  for  fear  of 
this  being  but  a  prelude  (as  it  was  indeed  designed)  to  some 
Operation. 

"  The  small  wound  was  now  puffy  and  livid ;  the  adjacent 
skin  began  to  be  undermined,  and  the  probe,  when  introduced, 
ran  along  some  extent  of  naked  bone.  The  pulse  had  risen  be- 
yond a  hundred,  the  tongue  was  white,  the  belly  still  costive, 
and  the  night  of  the  14th  he  passed  in  a  sleepless  perturbed 
state,  succeeded  in  the  morning  with  headach,  a  permanent 
sense  of  coldness,  sensibility  to  light,  and  that  character,  in  his 
features,  and  in  all  his  motions,  of  oppression  and  extreme  lan- 
guor, which  is  inseparable  from  a  suppurating  brain.  An  un- 
informed person  would  expect  suppuration  of  the  brain  to  be 
marked  by  convulsions  or  delirium,  while  one  at  ail  acquainte  d 
with  such  scenes  knows,  that  it  is  distinguished  only  by  extreme 
weakness,  not  by  the  violence,  but  bv  the  total  absence  of  symp- 
toms. The  man  knows  not  what  ails  him  ;  the  surgeon  per- 
ceives his  condition,  but  the  patient  hardly  complains,  unless  it 
be  of  sighing,  oppression,  slight  confusion  of  head,  shivering, 
with  a  feeling  of  coldness  at  the  accession  of  each  febrile  parox- 
ysm, and  trembling  of  the  hands,  and  tottering  of  the  knees, 
when  either  his  mind  is  alarmed,  or  he  endeavours  to  exert  his 
strength. 

"  This  man  I  had  destined  for  the  knife,  conscious  that  no 
earthlv  power  could  save  him,  if  that  suppuration  was  allowed 
to  come  to  maturity,  which  was  plainly  begun.  But  he  was 
reserved  for  a  different  fate ;  for  the  natural  course  of  rotation 


Of  Suppuration  of  the  Brain.  295 

of  the  hospital  having  delivered  him  into  other  hands,  I  met 
him  wandering  in  the  cold  stairs  of  the  hospital,  his  eyes  indeed 
open,  but  his  senses  gone,  at  the  moment  he  should  have  been 
under  the  operation  of  trepan.  On  the  13th  day  an  incision  had 
been  made,  so  as  to  prolong  the  cut  on  his  ht ad,  and  expose 
the  naked  part  of  the  scull,  which  was  nearly  on  the  top  of  the 
head,  close  by  the  sagittal  suture.  The  bone  was  bare,  and  was 
known  to  be  so  for  many  days  ;  but  it  was  not  supposed  dead. 
The  incision  healed,  or  seemed  at  least  in  a  healing  condition  ; 
and  for  his  sickness,  effervescing  draughts  were  prescribed.  He 
continued,  with  slight  variations  of  pulse,  countenance,  and  in- 
tellect, in  the  same  ailing  condition,  trom  the  13th  to  the  17th 
day  ;  but  his  vomiting  was  now  severe  ;  his  rigours  lasted  some- 
times half  an  hour ;  his  complexion  was  wan  ;  his  features  con- 
tracted and  pinched  ;  his  eye  heavy  and  melancholy  ;  his  fever 
increased,  and  his  pulse  beating  112;  and  though  generally 
feeble,  it  was  sometimes  very  strong:  even  in  the  hour  of  visit, 
his  vomiting  was  so  incessant,  his  shiverings  so  violent,  and 
his  pulse  at  the  same  moment  so  weak  and  trembling,  that  it 
could  not  be  felt.  On  the  18th,  the  confusion  of  head,  the 
ringing  of  the  ears,  the  fever  and  shiverings,  and  all  the  marks 
of  disorder,  were  so  much  increased,  that  the  operation  could  be 
no  longer  delayed,  but  unhappily,  the  man  was,  by  eighteen 
days  of  suffering,  reduced  so  very  low,  that  the  chance  of  his 
being  saved  by  it  was  indeed  very  slight.  Upon  perforating 
the  scull,  a  profusion  of  ripe  pus  flowed  from  the  trepan-hole  ; 
and  he  was  committed  to  bed,  where  he  passed  an  indifferent 
night.  In  the  morning,  though  no  shiverings  were  reported,  he 
was  chill ;  and,  in  place  of  the  oppressed  and  dejected  counte- 
nance which  he  had  before  operation,  his  looks  were  wild,  and 
his  pulse  extremely  rapid. 

i%  On  the  second  day  after  the  operation,  the  dura  mater 
looked  blaik  and  sloughy,  the  discharge  fetid,  the  matter  con- 
tinued to  flow  profusely  from  the  trepan-hole;  yet  his  looks  had 
changed  again  from  wild  and  distracted  to  oppressed  and 
anxious  ;  the  shiverings,  he  said,  had  ceased,  because  he  had 
refrained  trom  cold  drinks,  but  his  head  was  sadly  confused. 
On  the  3d  dav  he  fell  lower ;  his  senses  were  perfect,  but  his 
looks  expressed  unspeakable  distress  :  the  matter  was  brown, 
thin,  and  fetid,  the  wound  dry  and  glazed,  the  skin  hot,  and 
the  pulse  feeble  and  quick,  and  the  breathing  oppressed  :  with- 
out having  shiverings,  he  had  frequent  chillness ;  with  less 
feeling  of  pain  in  the  head,  he  has  a  miserable  feeling  in  eve- 
ry part  of  his  body.  By  the  4th  day,  he  had  fallen  extremelv 
low  ;  the  universal  uneasiness  seemed  very  distressing  ;  his 
pulse  extremely  weak;  his  voice  feeble  ;  his  features  shrunk ; 


296  Of  Suppuration  cf  the  Brain. 

he  never  slept,  but  moaned  and  tossed  continually.  On  the 
evening  of  the  5th  day,  after  a  severe  shivering,  he  sweated 
protuseh  ;  his  features  shrunk  perceptibly,  his  pulse  was  ex- 
tremely quick,  his  extremities  cold ;  the  night  was  passed  in 
great  disorder ;  he  struggled  to  get  out  ot  bed,  and  towards 
morning  fell  low,  and  expired." 

The  affidavit  which  1  presented  on  this  occasion  to  the  ma- 
gistrates, I  have  unfortunately  lost.  But  in  this  case,  I  have 
given  a  faithful  picture  of  a  condition  of  the  system  which  I 
have  often  observed  and  watched,  from  the  slightest  glimmer- 
ings of  danger,  to  the  last  tatal  struggle  of  delirium  or  convul- 
sive tremors.  By  this  instructive  case,  you  are  taught  at  once 
the  slightness  of  the  symptoms, — the  danger  inseparable  from 
these  phenomena  of  shiverings  and  puffy  tumour  combined, — 
the  deadly  suppuration  that  infallibly  lurks  under  a  dry  and  dis- 
coloured piece  of  cranium, — the  folly  of  delaying,  till  deadened 
bone  degenerates  actually  into  black  caries !  and  you  are  now 
conscious,  that  though  the  fate  of  the  patient  is  terrible,  the 
symptoms  are  not  so  :  that  the  most  deadly  and  decisive  are, 
debility,  anxiety,  shiverings,  and  slight  confusion  of  head  :  that 
to  wait  for  symptoms  is  to  wait  for  death,  for  the  first  slight 
convulsion,  or  decided  delirium,  is  the  immediate  forerunner  of 
death. 

The  case  I  am  now  about  to  lay  before  you,  is  of  a  very  dif- 
ferent complexion.  u  Elizabeth  Barrow,  a  woman  of  the  most 
dissolute  life  and  manners,  about  thirty  years  of  age,  was  knock- 
ed down  in  the  dark,  in  a  drunken  tumult,  with  a  candlestick, 
poker,  or  some  such  weapon,  but  immediately  recovered  her 
senses,  and  continued  in  health. 

11  The  blow  she  had  received  was  near  the  vertex,  upon  the 
corner  of  the  parietal  bone,  and  not  far  from  the  sagittal  suture  ; 
and  there  rose  over  the  contused  part  a  circular  tumour,  not  ex- 
actly a  puffy  tumour,  but  rather  aneurismal,  containing  blood. 
For  six  weeks  the  tumour  was  stationary,  and  the  woman, 
though  weakly,  and  having  pains  in  the  head,  was  without  any 
formal  complaint.  Perhaps  there  is  no  greater  mark  of  a  dis- 
solute life,  and  vicious  dispositions,  than  a  disregard  of  health  ; 
and  this  woman  ran  her  usual  course  of  vice  and  wickedness, 
undisturoed  with  any  thoughts  concerning  her  health,  till  febrile 
paroxvsms  and  pains  of  the  head  forced  her  to  apply  to  a  sur- 
geon, who  opened  the  tumour,  which  was  then  of  the  size  of  a 
hen's  egg,  with  the  point  ol  a  lancet,  and  it  discharged  chiefly 
blood.  But  the  puncture  soon  closed,  matter  gradually  collect- 
ed, and  the  tumour  was  soon  of  its  original  size.  In  a  month 
more,  it  was  again  opened,  and  discharged  blood  mixed  with 
matter,  healed  again,  and  again  formed. 


Of  Suppuration  of  the  Brain.  297 

"  The  tumour  was  pointed,  and  about  half  the  size  of  a 
tennis-ball,  soft,  puffy,  and  little  elastic.  The  centre  soft  and 
fluctuating,  the  circumference  hard,  firm,  and  bulging  ;  the 
bottom  solid,  and  giving  that  very  peculiar  feeling,  by  which 
we  are  apt  to  be  deceived,  in  recent  extravasations  of  blood  ;  it 
felt  as  if  the  tumour  covered  a  very  remarkable  depression  of 
the  scull.  Upon  laying  it  open  with  free  incisions,  the  matter 
which  flowed  was  thick  and  purulent,  much  mixed  with  blood; 
one  of  the  arteries  of  the  scalp  bled  profusely  ;  the  bune  was 
felt  rough  and  scabrous  to  a  great  extent,  and  from  part  of  its 
surface  a  loose  fungous  growth,  so  loose  that  you  could  push 
the  point  of  your  finger  through  it,  protruded  into  the  cavity 
of  the  abscess.  In  these  circumstances,  how  to  proceed  was  in- 
deed a  question  of  delicacy.  In  a  recent  contusion,  with  even 
the  slightest  of  these  symptoms,  where  there  was,  with  occasion- 
al shiverings,  a  naked  bone  at  the  bottom  of  a  puffV  abscess,  the 
rule  would  have  been  express.  But  this  woman  was  in  appa- 
rent health  ;  much  time  had  elapsed  without  any  signs  of  dan- 
ger ;  the  bone  might  be  carious  merely  on  its  external  surface, 
and  might  exfoliate,  or  might  granulate,  (as  indeed  it  did  in 
the  end  granulate)  :  There  could  be  no  apology  lor  precipitate 
operation  ;  there  seemed  to  be  time  for  reflection  ;  the  perfo- 
ration of  the  cranium  was  accordingly  deferred. 

u  But  she  had  been  induced  to  present  herself  to  the  sur- 
geons, from  having  headachs,  sometimes  severe,  with  confusion 
of  head,  chillntss,  and  fever-fits,  which  were  very  distressing  ; 
she  was  at  the  same  time  so  nervous  and  alarmed,  and  her  suf- 
ferings altogether  so  great,  that  she  received  with  pleasure 
the  first  proposal  of  an  operation.  The  catamenia,  which  had 
disappeared  after  the  blow,  were  now  flowing,  but  were  sud- 
denly stopped  with  an  increase  of  headach,  a  costive  belly,  a 
hot  skin,  and  a  febrile  pulse,  counting  always  above  jOO.  On 
the  4th  day  of  putting  herself  under  our  care,  the  incisions 
being  already  very  free,  the  operation  of  trepan  was  performed 
by  Mr.  Lawson,  who  made  his  perforation  near  the  sagittal  su- 
ture, and  on  the  anterior  part  of  the  caries,  through  a  very  un- 
usual thickness  of  bone  :  but  the  bone  was  in  part  alive  ;  a 
great  profusion  of  blood  flowed  from  the  cancelli ;  and  the  mo- 
ment the  inner  table  was  divided,  and  before  the  perforation 
was  complete,  matter  spouted  up  in  great  profusion  by  the  sides 
of  the  saw. 

"  The  night  following  the  operation,  the  patient  was  restless 
and  feverish,  for,  upon  opening  an  abscess  within  the  scull,  as 
in  opening  one  in  any  part  of  the  body,  the  fever  and  nervous 
symptoms,  hardly  perceptible  before,  became  very  conspicuous. 
Though  the  wound  looked  well,  the  head  was  in  confusion,  and 

2P 


298  Of  Suppuration  of  the  Brain. 

she  became  extremely  sensible  to  noise  or  light.  The  succeed- 
ing night  was  calm  ;  and  the  headach,  which  was  violent  the 
first  day,  was  relieved  by  rest  and  quietness  on  the  second.  The 
flow  of  matter  from  the  surface  of  the  dura  mater  was  good  and 
copious,  and  its  surface  began  to  granulate. 

"  Even  on  the  5th,  I  found  her  complaining  of  great  depres- 
sion of  spirits,  nausea,  and  sickness,  and  great  pain  of  the  head  ; 
but,  by  the  prudent  use  of  clysters,  of  opiates,  and  a  little  wine 
dashed  with  water,  the  sickness  abated  in  two  days,  the  wound 
contracted  apace,  the  pus  was  thick  and  well-tormed,  the  sur- 
face of  the  dura  mater  was  florid  and  granulating.  By  the 
8th  day,  the  margins  of  the  trepan-hole  were  red  and  fleshy, 
and  the  whole  surface  of  the  diseased  scull  was  covered  with 
a  rich  pile  of  granulations.  In  about  twenty  days  more,  the 
wound  was  contracted  ;  the  cicatrix  of  the  scull,  scalp,  and  du- 
ra mater,  consolidated  ;  and  the  woman  perfectly  cured  in  six 
weeks."* 

Without  any  suggestion  on  my  part,  you  will  reap  every  ad- 
vantage from  the  contrasting  of  this  with  the  preceding  case, 
and  learn  by  experience  the  duty  of  watching  with  extreme  so- 
licitude the  slightest  changes  of  the  eye,  countenance,  or  pulse  ; 
the  slightest  shiverings,  oppression,  or  sickness,  in  those  who 
have  this  contusion  of  the  scull. 

In  cases  of  fracture,  there  may,  indeed,  be  doubts  as  to  the 
propriety  of  operating :  the  danger  is  eventual,  the  operation 
merely  preventive,  Fracture  may  cause  a  suppuration  of  the 
brain  and  membranes  at  some  future  period  ;  but  contusion  is 
the  disease  itself,  it  is  the  actual  suppuration  of  the  brain,  an- 
nounced by  infallible  signs.  Of  all  the  cases  in  surgery,  this  is 
the  least  equivocal.  Of  those  who  have  fractures  of  the  scull, 
many  even  in  the  most  alarming  circumstances  survive  unas- 
sisted ;  but  in  contusion,  followed  by  suppuration,  unless  the 
scull  be  perforated,  unless  the  abscess  be  opened,  all  must  die. 

O'Halloran  says  a  thing  at  once  untrue  and  discouraging  ; 
untrue  at  least  as  a  general  aphorism,  and  discouraging,  since 
it  tends  to  make  us  indifferent  to  the  most  interesting  question 
in  practice,  and  to  the  condition  of  many  who  might  be  saved  : 
**  In  the  course"  (says  O'Halloran)  "  of  many  years  practice 
and  careful  observation,  I  cannot  give  myself  credit  for  a  sin- 
gle cure  I  ever  performed  in  this  way,  (by  trepaning)  when 
the  symptoms  of  deposit  xvere  formed ;  for  whether  the  patient 

*  This  woman,  who  made  no  fecret  of  her  vicious  life,  or  fyphilitic  taints,  had 
a  new  fuppuration  over  the  trepaned  part  of  the  fcull  nine  months  after  the  ope- 
ration ;  the  abfeefs  was  opened;  a  fcale  of  bone  exfoliated;  and  fhe  had  a  mer- 
curial courfe  adminiftcrcd  to  her  for  the  cure  of  very  fufpicious  pains,  accom- 
panied with  flight  nodes  on  the  clavicle  and  fternum. 


Of  Suppuration  of  the  Brain.  299 

was  or  was  not  trepaned,  the  scene  closed  ivith  death."  This 
clous  but  prove  the  culpable  delays,  even  of  this  good  practical 
surgeon,  forewarned  as  he  was  ot  the  dangers  of  matter  being 
formed;  and  demonstrates  to  us,  that  those  who  die  are  lost 
by  temporising  and  timid  counsel.* 

Pott,  our  celebrated  surgeon,  whose  opinions  and  writings 
are  so  justly  esteemed,  was  engaged  in  that  tumult  of  practice, 
which  left  him  little  time  to  frame  general  laws  ;  yet  he  could 
not  fail  to  act  with  good  sense  and  skill  in  each  individual  case: 
he  was  sure  to  practise  right,  but  in  danger  of  teaching  wrong, 
or  at  least  imperfectly  :  his  opinions  want  but  one  short  expla- 
nation, lor  the)  are  such  as  will  never  be  disputed,  where  they 
are  understood. 

"For  my  own  part,  (says  Pott)  I  have  no  doubt,  that,  al- 
though by  establishing  it  as  a  general  rule  to  perforate  in  all 
cases,  some  few  would  now  and  then  be  bubjected  to  the  ope- 
ration, who  might  have  done  very  well  without  it;  yet,  bv  the 
same  practice,  many  a  valuable  life  would  be  preserved,  which 
must  be  inevitably  lost  without  it,  there  being  no  degree  of  com- 
parison between  the  good  to  be  derived  Irom  it,  when  usedfe/r- 
ly  as  a  preventive ;  and  what  may  be  expected,  if  it  be  defer- 
red till  an  inflammation  of  the  dura  mater,  and  a  symptomatic 
fever,  make  it  necessary." 

A  preventive  !  How  could  the  operation  of  trepan  prevent 
inflammation  of  the  dura  mater?  Could  perforating  the  scull 
with  a  saw,  tearing  up  the  vessels  which  naturally  connect  it 
with  the  dura  mater,  and  exposing  that  membrane  to  rude 
dressings,  and  the  touch  of  instruments,  prevent  inflammation? 
Yes,  surely:  it  could  prevent  all  the  dangerous  consequences 
of  inflammation  :  it  could  prevent  matter  accumulating,  nnd 
inflammation  spreading  :  it  could  prevent  ulceration  pene- 
trating to  the  brain :  it  could  convert  an  extending  and  most 
dangerous  abscess  into  an  open  sore  :  it  could  enable  the  dura 
mater  to  granulate  and  unite  with  the  integuments.  There  is  no 
good  purpose  that  a  timely  operation  might  not  serve  ;  and  if 

*  The  opinion  of  Archigenes,  as  cited  by  Mr.  Bell,  is  probably  correct  :— 
"  When  the  dura  mater  is  inflamed,  then  come  fhiverings,  and  fever,  and  flufhings 
of  the  face  quite  difproportioned  to  the  degree  of  fever;  difturbed  fleep,  eyes  hea- 
vy and  fwelled,  a  fore  flabby  and  foul  with  ill-digefted  pus;  fometunes  puftules 
cover  the  tongue.      T/jofc  who  tie  chance  offafcty;  but  ivben 

hut  a  httlc  delayed,  they  almost  ahuays  die.''  Whenever  lymptoms  of  inflam- 
mation of  the  brain,  or  its  membranes,  take  place,  if  there  be  a  puffy  tumour, 
and  no  wound  of  the  integuments,  they  fhould  be  immediately  laid  opui  down  to 
the  bone.  The  head  fhould  be  fhuved,  and  a  blifler  applied  over  the  whole  of  it, 
except  immediately  upon  the  wound.  Bleeding  and  purging  muft  likewife  be  ve- 
ry copioufly  ufed,  and  the  ft  rid  eft  abftii  fed,  in  cider,  if  poflible,  to 
prevent  the  formation  of  matter,  for  fhould  this  happen,  no  fublequent  treat- 
ment will  probably  Jave   the  patient.     .S. 


300  Of  Suppuration  of  the  Brain. 

the  trepan  be  used  only  when  it  should,  there  can  be  no  vessels 
torn;  nor  will  the   dura  mater  be  exposed,  lor  the  dura  mater 
is  previously  in   a  state  of  suppuration,  and  separated  trom  the 
inner  surfare  of  the  scull.     We  find,  by   his  examples,    that 
Pott  meant,  by  prevention,  the  anticipation  of  worse  s)mptoms, 
the  preventing  of  death  ;  that  he  regarded  the  operation  as  pre- 
ventive, when  it  was  used  so  early,  that  though  the  dura  ma- 
ter had  previously  suppurated,  the  suppuration  was  but  slight ; 
when,  by  the  timely  opening  of  such  abscess,  it  was   prevented 
reaching  the  b*-ain,  when  the  dura  mater  granulated  easily,  and 
healed  naturally.     Unless  we  were  to  take  an  ungenerous  ad- 
vantage of  a  slight  inaccuracy  of  language,  and  dispute  the  words 
of  this  author,  while  we  understand  his  sense,  we  mi  st  acqui- 
esce  in  the  principles  he   has  laid  down,  and  give  him  honour 
and  praise,  for  the  comprehensive  and  judicious  views  he  has 
taken  of  what  he  saw  going  on  around  him,  for  the  honest  and 
manly  boldness  with    which  he  has  declared  his  principles,  so 
different  Irom  those  transmitted  to  us  by  the  writers  of  the  pre- 
ceding age,  and  for  the  generous  manner  in  which  he  has  taken 
upon  himself  a  responsibility  of  the  most  critical  nature,  resist- 
ing alone  all  that  torrent  of  reproach  which  was  likely  for  a  time, 
and  especially  in  his  own  day,  to  be  attached  to  what  may  be 
termed  Hospital  Practice,  harsh  and  cruel  surgery.     But  study 
his  cases,  and  you  will  perceive,  that  whenever  Pott  trepaned, 
the  patient  was  in  danger,  the  bone  bare,  the  tumour  puffy,  or 
the  wound  (il  there  was  one)  fetid,  the  pulse  quickened,  the 
face  flushed,  the  head  in  confusion,  and  the  fatal  shiverings  be- 
gun ;  and  these  are  marks,  not  of  future  danger,  but  of  actual 
suppuration,     it  is  fortunate  for  mankind,  when  new  doctrines 
are  not  extravagant ;  when  those  who  enjoy  the  public  favour, 
have  won  it,  not  by  the  capricious  and  captivating  effusions  of 
gt  nius,  but  by  the  lasting  attraction  of  sober  inquiry  and  sterling 
Sense  ;  when  a  popular  work  contains  principles  which,  being 
founded  on  experience,  will  stand  the  test  of  time. 


(     301     ) 


DISCOURSE  XVIII. 


OF  FRACTURES  OF  THE  SCULL. 


SECTION    I. 


Preliminary  Observations, 

X  HE  old  surgeons  allowed  not  the  slightest  chink,  fissure,  or 
rima,  as  they  called  it,  to  escape  investigation ;  the  slightest 
fissure,  or  the  bare  suspicion  of  one,  was  the  signal  for  apply- 
ing the  trepan,  and  there  was  nothing  so  gratifying  to  them  as 
a  Iracture  so  circumstanced,  or  an  extravasation  so  extensive  as 
to  require,  or  at  least  to  vindicate,  the  application  of  the  trepan, 
ten  or  twelve  times.  It  was  not  that  the  crown  of  their  instru- 
ment was  small,  and  thence  its- application,  necessarily  frequent, 
to  make  even  a  moderate  opening;  they  scrupled  not,  after 
making  numerous  perforations,  to  cut  up  all  the  intermediate 
pieces  of  bone  with  the  saw,  and  clear  away  a  whole  parietal 
bone,  or  half  the  scull.  This  was  the  pomp  and  pride  of  sur- 
gery in  former  times,  which  you  are  called  upon  to  imitate,  by 
the  approbation  with  which  such  facts  are  now  commemorated, 
and  by  the  very  form  of  instruments  put  into  your  hands,  which 
are  by  no  means  calculated  to  make  very  moderate  openings : 
the  making  very  large  openings,  either  by  large  trepans  or  fre- 
quent perforations,  is  a  practice  highly  commended  in  every 
book,  and  the  extent  of  the  fracture  is  usually  reckoned  the  sole 
limits  of  the  opening. 

"  In  excessive  fractures  (says  Dionis)  we  should  not  hesi- 
tate to  make  two,  three,  or  four  perforations,  if  required.  A 
young  girl,  of  eleven  or  twelve  years  of  age,  having,  by  a  fall 
down  stairs,  fractured  the  whole  of  the  parietal  with  a  part  of 
the  temporal  bone,  Mr.  Marechal  trepaned  her  next  day 
in  two  places:  he  made  his  son  trepan  her  a  third  time;  he 


3  02  Of  Fractures  of  the  Scull. 

allowed  my  son,  who  was  present,  to  trepan  her  a  fourth  time : 
the  next  day,  applied  the  trepan  twice  more,  and  in  the  end  had 
actually  perforated  twelve  times,  and  cured  her  completely.  So 
precious  an  example  shows  how  little  reason  we  have  to  be  sur- 
prised at  the  frequent  application  of  the  trepan."  Here  is  a 
doctrine  laid  down,  which,  I  fear,  there  is  little  occasion  to 
enforce  ;  and  I  cannot  but  persist  in  being  surprised  and  shock- 
ed, at  the  frequent  and  large  perforations  which  I  have  both 
read  of  and  seen,  and  cannot  but  think  of  these  veterans  in  sur- 
gery in  no  very  amiable  light,  when  I  see  them  indulging  their 
boys  in  the  novelty  of  operating,  probably  on  very  slight  com- 
pulsion. 

These  reports,  and  especially  the  last  clause  of  this  para- 
graph, viz.  "  that  we  should  not  be  surprised  at  the  number  of 
trepans,"  have  plainly  a  reference  to  the  ever  memorable  ope- 
ration performed  in  the  time  of  King  William's  wars,  on  Philip 
Count  of  Nassau,  by  Henry  Chadborn,  chirurgeon.  Godifre- 
dus,  chief  surgeon  to  the  States  of  Holland,  mentions  with  par- 
ticular exultation  this  operation  performed  by  his  friend,  who 
trepaned  the  cranium  of  the  Count  of  Nassau  twenty-seven 
times,  and  ascertained  the  fact  by  the  most  indisputable  autho- 
rity, for  he  made  the  said  Duke  of  Nassau,  after  he  was  reco- 
vered, on  the  12th  day  of  August,  1664,  write  the  following 
curious  certificate.  M  I  the  under  written  Philip  Count  Nas- 
sau, hereby  declare  and  testify  that  Mr.  Henry  Chadborn  did 
trepan  me  in  the  scull  twenty-seven  times,  and  alter  that  did 
cure  me  well  and  soundly." 

Mr.  Pott,  a  surgeon  of  unrivalled  excellence,  whose  influence 
was  fairly  acquired,  (but  let  those  who  have  influence  with  their 
profession  use  it  discreetly  and  wisely,  let  them  ponder  well  the 
maxims  they  announce)  fell  into  a  system  of  practice  so  bloody 
and  enterprising,  that,  in  the  few  years  which  have  elapsed  irom 
his  death,  it  has  fallen  into  utter  discredit,  and  he  delivered  his 
maxims  in  a  style  so  decisive  and  imperative  as  to  impose  even 
now  upon  the  younger  part  of  the  profession,  while,  by  all  who 
judge  tor  themselves,  his  practice  is  abandoned  :*  no  wonder 
it  is  abandoned,  being,  in  every  point,  except  one,  repugnant 
to  good  principles.  He,  in  every  case,  whether  slight  or  dan- 
gerous, cuts  off  the  xv hole  puffy  tumour,  scalping  the  part  with 

*  In  the  accounts  which  we  have  of  the  former  practice  in  France,  it  is  related 
that  furgeons  mack  numerous  ptrlorations  along  the  whole  track  of  a  fradture  of 
the  cranium  ;  and,  as  far  as  I  am  able  to  judge,  without  any  very  clear  defigf]. 
Mr.  Pott  ulfo  advifes  inch  an  operation,  with  a  view  to  prevent  the  inflammation 
and  fuppuration  of  the  dura  muter,  which  he  fo  much  apprehended.  But  many 
cafes  have  occurred  of  late,  where,  even  in  fracture-  with  depreflion,  the  patients 
have  done  well  without  an  operation.    Abcrnttby's  £J/ayt. 


Of  Fractures  of  the  Scull.  303 

a  circular  incision :  he,  in  every  suppuration  of  the  dura  mater, 
and  in  every  case  of  extravasated  blood,  applies  the  largest  tre- 
pan, though  he  has  no  other  purpose  than  to  give  vent  to  such 
matter  or  blood  :  dissatisfied  (as  he  had  reason  to  be)  with  the 
small  trepans  in  common  use,  he  ordered  them  to  be  forged 
for  him  of  an  unusual  size,  and  did  not  spare  their  liberal  ap- 
plication. After  perforating  the  scull  once,  in  place  of  provid- 
ing by  other  means  for  the  free  evacuation  of  the  matter,  he 
applied  his  trepan  again  and  again,  till  all  the  suppurated  sur- 
face of  the  dura  mater  was  displayed,  declaring  it  to  be  his  in- 
tention to  cut  away  all  that  part  of  the  scull,  however  extensive, 
under  which  the  suppuration  existed. 

"  When  the  operation,  says  Mr.  Pott,  has  been  performed, 
not  as  a  preventive,  but  to  give  discharge  to  matter,  the 
only  chance  of  relief  is  from  laying  bare  a  large  portion  of  the 
dura  mater,  that  the  discharge  may  be  as  free,  and  the  confine- 
ment as  little  as  possible,  as  nothing  but  this  can  do  good."  And 
again  he  says,  u  Yet  perforation  is  absolutely  necessary,  in  seven 
cases  out  of  ten  of  simple  undepressed  fracture  of  the  scull."  He 
does  by  no  means  deliver  these  rules  with  temperance  or  mo- 
desty, but  says,  M  I  am  as  well  satisfied  of  this  as  of  any  truth 
which  repeated  experience  may  have  taught  me." 

Such  bold  words  lose  all  power  when  we  begin  to  find  how 
ill  experience  may  teach  a  man,  and  how  unreflectingly  such 
language  is  used.  At  first,  the  reader  would  naturally  say  with- 
in himself,  "Surely  Mr.  Pott,  before  he  could  use  such  confi- 
dent language,  must  have  seen  repeated  and  afflicting  proofs  of 
the  necessity  of  using  the  trepan  :''  but  to  his  utter  confusion, 
he  finds  the  very  words  repeated  in  commending  the  now  ob- 
solete operation  of  scalping,  and,  indeed,  on  every  occasion, 
trivial  or  important,  for  it  is  with  this  author,  a  manner,  and  no 
more:  He  says,  uThe  way  of  doing  this,  (viz.  of  scalping)  has 
formerly  been  the  occasion  of  much  difference  of  opinion;  but 
there  can  be  no  doubt  about  the  greater  propriety  of  remov- 
ing a  piece  of  scalp  for  this  purpose,  by  an  incision  in  a  circular 
form  /"  Even  when  Mr.  Pott  applied  the  trepan,  not  on  ac- 
count of  any  present,  but  of  some  eventual,  perhaps  imaginary 
danger,  he  set  no  limits  to  the  number  of  perforations,  but  the 
extent  of  the  fracture.  He  says,  "  If  the  trepan  be  applied  in 
a  preventive  sense  merely,  the  lengt/i  of  the  fracture  must  de- 
termine the  number  !  one  or  two  only  may  be  made  at  first." 
In  short,  all  his  precepts,  most  of  his  cases,  and  even  the  very 
form  and  size  of  his  instruments,  contributed  to  renew  and 
strengthen  that  passion  for  frequent  perforations  and  large  open- 
ings of  the  cranium,  which  the-  decline  of  false  Laming  and  the 
progress  of  plain  good  sense  had  almost  allayed :  and  1  will  ven- 


304  Of  Fractures  of  the  SculU 

ture  to  say,  that  whoever  has  studied  his  writings,  or  imbibed 
his  principles,  must  imagine  that,  in  the  work  of  trepaning,  he 
can  never  do  too  much,  and  is  only  blamable  where  he  has  left 
any  possible  thing  undone.  But  a  few  men  of  strong  natural 
sense,  among  whom  Platner  is  one,  have  had  the  sense  and  cou- 
rage to  protest  against  such  frequent  applications  of  the  trepan. 
M  There  is  bv  no  means  any  necessity  (says  Platner)  to  have 
recourse,  in  all  cases  of  fissure  or  fracture  of  the  scull,  to  in- 
struments to  cut  them  out  with :  where  there  are  no  evil  signs, 
the  trepan  is  not  required:"  but  unhappily  the  most  extravagant 
and  foolish  things  are  best  remembered,  and  oftencst  repeated, 
while  these  solid  remarks  of  a  man  of  skill  and  judgment  are 
but  too  easily  forgotten. 

We  find  that  it  had  been  the  practice  of  the  older  surgeons 
not  only  to  apply  their  trepans  the  whole  length  of  a  longitudi- 
nal fracture,  but  along  each  of  the  radii  of  a  star-like  fracture, 
and  in  short,  to  repeat  the  expression  of  Platner,  *  to  cut  it  out.' 
The  testimonies  of  the  most  sensible  writers  are  against  the 
operation,  and  most  unfavourable  to  the  men  who  have  indulged 
it,  for  it  has  been  ascribed  not  to  reason,  but  to  pride.  u  If 
the  opening  (says  Wiseman)  in  the  fractured  scull  be  not  suf- 
ficient, make  one  in  the  most  declining  part,  and  raise  up  the 
bones,  and  free  the  membrane  of  whatever  may  offend  it,  but 
do  not  take  out  any  more  bone  than  needs  must^Yikt  some  of  those 
surgeons  I  have  met  carrying  them  about  in  their    pockets, 

BOASTING    IN    THAT    WHICH    WAS   THEIR    SHAME."       Never  is 

the  apology  wanting  to  those  who  are  proud  of  making  nume- 
rous perforations :  if  they  do  not  find  a  conspicuous  depression, 
or  a  great  length  of  fracture,  they  affect  to  be  seeking  for  pus, 
or  that  they  are  anxious  to  let  out  extravasated  blood.  They 
dare  not  forsooth,  after  making  the  necessary  opening,  allow 
the  pus  to  ooze  out  gradually,  or  the  blood  to  melt  down  and 
be  resolved  into  serum.  They  affirm,  4l  that  it  is  infinitely 
more  dangerous  to  wait  the  dissolution  of  the  coagulated  blood 
than  to  make  numerous  perforations  for  the  evacuation  of  such 
pernicious  juices,  for  not  only  such  openings  as  that  we  have 
just  mentioned  of  12  trepans,  but  openings  much  more  exten- 
sive, close  easily."  w  I  have  seen  surgeons,  says  Ravaton, 
so  infatuated,  so  desperat'.  1\  bent  on  discovering  abscess  on  the 
dura  mater,  that,  after  applying  six  crowns  of  the  trepan,  they 
would,  I  verily  believe,  have  pulled  away  all  the  remaining 
bones  of  the  cranium,  had  not  their  patients  been  delivered  by 
death  from  such  operations."  In  short,  their  doctrines  and 
practice  outraged  common  sense :  every  thing  was  to  be  done 
by  the  surgeon,  nothing  left  to  nature  :  every  depression  was  to 
be  elevated ;  the  whole  matter  to  be  evacuated  j  the  whole  ex- 


Of  Fractures  of  the  Scull.  305 

tent  of  the  extravasation  to  be  covered  by  trepan-holes,  and  the 
limbs  and  whole  extent  of  a  radiated  fracture  were  to  be  cut 
away.  There  were  no  limits  assigned  for  these  openings,  but 
the  extent  of  the  extravasation  or  fracture,  and  they  were  well 
contented  to  find  that  40  crowns  of  the  trepan  might  upon  ne- 
cessity be  applied  to  the  human  scull. 

But  there  is  a  scene  of  practice  very  different  from  this,  where 
men,  engaged  in  the  actual  duties  of  the  profession,  in  peace  or 
in  war,  in  cities  or  in  the  field,  learn  to  look  coolly  on  wounds 
of  every  description,  and  know  from  experience  what  nature 
will  do,  and  how  impertinent  and  vain  those  operations  are.  It 
often  happens  to  grooms  or  farriers,  trimming  horses  feet  with 
too  little  precaution,  that  the  horse  striking  out,  thty  receive 
the  kick  full  in  the  forehead  :  the  scalp  is  torn  up,  the  scull  ma- 
nifestly injured,  or  not  a  little  depressed  ;  these  men  live  a 
coarse  irregular  life,  and  yet  such  fractures  heal  easily,  but,  were 
the  trepan  applied  on  every  such  occasion,  we  should  have  many 
dismal  scenes.  It  often  happens  that  boys  playing  with  horses, 
plucking  hairs  from  a  colt's  tail,  for  example,  are  knocked  down 
by  a  kick  in  the  forehead  ;  often  the  bone  is  deeply  depressed, 
very  often  the  marks  of  the  heels  or  caukers  of  the  shoe  are 
impressed  upon  the  os  frontis  ;  sometimes  apiece  of  the  bone  is 
actually  turned  upwards  along  with  the  scalp  ;  but  the  scalp  being 
re-applied  to  the  scull,  the  splinters  of  the*bone  picked  away,  and 
the  ragged  integuments  smoothed  and  secured  with  stitches,  the 
boy,  without  one  hour  ol  sickness,  recovers  as  if  his  wound 
were  only  of  the  skin.  But  were  such  pieces  of  depressed  or 
shattered  bone  cut  out ;  were  openings  made  at  all  proportioned 
to  the  depressions,  or  to  the  extent  of  the  fractures  ;  were  the 
delicate  dura  mater  of  a  boy  left  exposed  to  that  force  of  circu- 
lation, which  dilates  the  brain,  and  fretted  by  every  stroke  of 
the  arteries  against  the  margins  of  the  opening,  the  dura  mater 
would  slough,  perhaps,  the  brain  protrude  and  suppurate,  and 
the  boy  expire  howling  and  convulsed.  Examples  of  such  im- 
prudence and  such  consequence  I  shall  presentlv  relate,  for  I 
know,  that  when  my  business  is  to  impress  vou  with  any  prac- 
tical truth,  the  best  way  of  confirming  the  maxim,  and  making 
you  feel  the  force  of  it,  is  plainly  to  represent  the  scene* 

Often  the  recovery,  where  the  scull  is  very  deeply  wounded, 
is  so  rapid,  as  to  surprise  those  even  who  are  the  most  resolute 
in  refraining  irom  the  use  of  the  trepan,  and  the  best  prepared 
to  expect  a  happy  issue.  The  faith  and  credit  of  Pareus  stand 
unimpeached;  and  the  case  he  relates,  of  a  cure  performed  with 
his  own  hand,  is  the.  most  remarkable  of  any  yet  recorded  ;  since 
even  the  segment  of  the  scull  itself  in  a  clean  sabre-wound,  ad- 
hered again  in  common  with  the  wounded  scalp.       "  I  advise 

2Q 


306  Of  Fractures  of  the  Scull. 

(says  Pareus)  wherever  there  remains  a  portion  of  the  skin  still 
connected  with  the  wounded  scalp,  that  neither  that  skin,  nor 
the  divided  portion  of  bone  be  cut  awav,  but  the  bone  sewed 
up  along  with  the  skin.  What  Celsus  commends  (says  Pareus) 
I  performed  in  the  case  of  Captain  llxdron,  who  was  a  short 
while  ago  wounded  in  thiscitv  with  a  sword  through  the  centre 
of  the  os  frontis,  the  bone  being  cut  down  the  length  of  three 
inches,  so  that  it  hung  over  his  face,  connected  with  the  scull 
onh  by  its  pericranium,  and  about  three  inches  of  the  fleshy 
scalp.  At  fust  sight,  I  questioned  whether  or  not  I  should 
complete  the  separation  of  this  piece  of  skin  with  its  adhering 
bone,  but  remembering  Hippocrates's  maxim  never  to  uncover 
the  brain,  1  cleansed  the  blood,  which  was  upon  the  dura  ma- 
ter, laid  up  the  separated  piece,  and,  for  the  better  retention 
thereof,  made  three  points  of  the  needle  in  the  upper  part,  and 
put  in  three  small  dossils  in  the  sides  of  the  wound,  the  whole 
being  so  nicely  replaced,  that,  by  God's  grace,  it  htalfd  perfect- 
ly, though  the  gentleman  was  otherwise  much  wounded  on  the 
face,  in  the  thigh,  and  in  the  right  breast.  I  finally  beseech 
you  (says  Pareus)  never  to  amputate  neither  skin  nor  bone,  lest 
the  brain  should  be  left  bare." 

In  the  work  of  Berengarius,  De  Fracturis  Cranii,  so  much 
and  justly  praised,  jou  have  no  instructions  for  discovering,  nor 
any  warrant  for  trepaning  fissures.  He  seems  to  have  been 
taught  a  very  different  practice  by  his  father  in  his  earliest}  ears. 
Thev  seem,  in  these  times,  always  to  have  felt  a  sort  of  trepi- 
dation when  they  sewed  the  scalp;  and  Berengarius  gives  many 
anxious  directions  about  undoing  the  stitches  upon  the  slightest 
appearance  of  fever  or  abscess  ;  but  still  he  directs  that  the  scalp 
be  sewed. 

Especially  when  the  bone  was  wounded,  they  feared  to  sew 
the  integuments  ;  yet  Berengarius,  while  he  complies  with  the 
rule,  relates  an  exception  highly  worthy  of  notice.  Ht  re- 
minds his  reader  that  he  had  advised  the  suture  of  the  scalp  on- 
ly when  the  bone  was  unhurt  and  the  pericranium  entire  ;  "  for 
a  suture  (says  Berengarius)  being  drawn  close  over  a  diseased 
bone,  the  patient  dies,  wherefore,  such  wound  must  be  dilated 
and  opened,  not  sewed  and  closed  :  Yet,  I  call  God  to  witness 
the  truth  of  the  following  narrative,  so  unprecedented  that  I  dare 
hardly  tell  whit  I  saw.  While  I  was  a  young  man,  a  snldier 
wounded  his  fellow  with  a  weapon,  and  cut  down  the  os  frontis 
from  its  upper  part  to  the  superciliary  ridge,  so  that  th<j  os 
frontis,  with  its  integuments,  hung  over  his  eves,  divided  from 
above  and  at  the  sides,  and  connected  only  below.  M)  lather 
went  first  to  his  assistance,  and  removed  tin-  or, in  from  ih  in- 
teguments ;  the  bone  was  the  whole  length  of  the  os  frontis  ; 


Of  Fracture's  of  the  Scull.  307 

the  dura  mater  was  untouched.  The  skin  of  the  forehead  was 
replaced  and  stitched  without  that  opening  at  the  lower  part  of 
the  wound  which  surgeons  are  accustomed  to  leave  as  a  drain 
for  the  mutter;  being  closed  with  white  of  eggs,  and  dressed 
daily,  n  was  in  ten  days  completely  re-united,  and  ever  after 
the  svslole  and  diastole  of  the  arteries  was  distinctly  seen  where 
the  bone  was  wanting.  This  I  have  put  down,  says  Berenga- 
rius,  to  make  medical  men  keen  and  courageous  in  curing 
wounds." 

Besides  these  instances,  in  domestic  life,  it  is  remarked,  to 
the  dishonour  of  our  trade,  that  in  times  of  war  and  trouble, 
when  men  are  not  allowed  to  take  care  of  their  wounds,  those 
who  are  least  cared  for  are  soonest  cured  ;  and  a  man,  who  is 
forced  to  wrap  a  clout  about  his  head  and  ride  for  his  life,  is 
safer  than  one  who  is  chambered  up,  dieted,  and  dressed,  per- 
haps (repaired  by  the  surgeon.  The  great  rebellion  was  lull 
of  such  adventures  and  hair-breadth  escapes,  many  of  which 
are  related  by  Wiseman  :  among  others,  that  of  "■  a  gentleman 
who,  a  day  or  two  before  the  battle  of  Worcester,  attending  the 
Earl  of  Derby  in  his  retreat  thither,  received  a  large  wound  be- 
tween the  sagittal  and  coronal  sutures  by  a  sword,  uhich  went 
through  the  cranium  to  the  dura  mater,  is  exceeding!)  remark- 
able :  the  membrane  was  covered  with  small  shivers  of  bones  : 
he  had  only  a  thin  linen  cap  over  it,  his  haste  not  permitting 
him  to  be  dressed,  and  it  may  be  it  was  the  better  for  him,  for 
if  dossils  had  been  hastily  crowded  upon  the  bones,  severe 
symptoms  would  have  followed;  whereas  the  shivers  lying 
lightlv  upon  the  membrane,  he  was  free  ;  and  being  ignorant 
of  his  danger,  rid  a  great  journey  :  I  after  took  them  out,  and 
dressed  the  membrane  with  digestives,  the  short  time  we  were 
together."  It  was  upon  such  proofs  that  Wiseman  came  to  be 
persuaded  of  this  general  truth,  that  w  recent  fracturks  of 

THE  CRANIUM   DO  FREQUENTLY    UNITE    LIKE  THOSE   IN    OTHER 

parts,  if  the  matter  hath  liberty  to  discharge  from  within. 
Therefore  having  raised  up  the  bones  that  are  loose,  dress  the 
others  dry.''* 

u  During  the  war,"  (says  Wiseman)  "  I  was  frequently  em- 
ployed in  the  dressing  of  some  one  person  or  other,  wherein  I 
have  seen  all  or  most  of  the  several  sorts  of  fractures.  I  have 
dressed  many  that  have  been  cut  through  the  scull,  the  shivers 
of  the  bone  lying  pashed  with  the  flesh  and jhe- hair ',  upon  the 
dura  mater  ;  yet  the  patient  hath  had  no  symptom  of  such  a 
wound."  Here,  in  a  few  sterling  words,  are  descriptions  which 
will  better  satisfy  all  your  doubts  than  the  most  learned  argu- 
ments. 

•   Wifenian,  page  113.  vol.  ii. 


\T 


308  Of  Fractures  of the  Scull. 

So  much  for  open  wounds,  when  the  clean  incision  of  a  wea- 
pon seems  to  have  done  the  business  ol  the  trepan.  But,  even 
in  cases  where  the  bone  is  fractured  with  a  wide  and  portentous 
fracture,  or  when  it  is  actually  depressed  in  a  way  which  might 
vindicate  the  application  of  the  trepan  ;  in  cases  where  it  re- 
quires some  courage  to  refrain  lrom  operating,  the  patient  is 
cured  w  iih  surprising  ease.  I  can  be  at  no  loss  in  proving  this 
in  a  thousand  various  forms  ;  if  I  could  feel  any  difficulty,  it 
must  be  only  in  selecting  the  cases  which  best  represent  the  va- 
riety of  circumstances.  In  Mr.  O'Haloran's  paperin  the  Irish 
Transactions,  we  find,  among  other  cases,  that  of  Edward  Pow- 
er, "who  received  a  desperate  wound  of  a  back-sword,  extend- 
ing from  the  top  of  the  coronal  bone  to  the  orbit  of  the  leftside, 
forming  an  extended  and  frightful  chasm,  in  which  were  includ- 
ed the  bone,  membranes,  and  brain.  It  bled  considerably,  as 
may  be  well  supposed.  He  remained  exposed  to  the  air  for 
near  three  hours  after,  and  had  not  so  much  as  a  bit  of  rag  to 
cover  it :  fever  and  inflammation  of  the  brain  might  reasonably 
be  apprehended  ;  yet,  by  a  couple  of  bleedings,  and  some  other 
antiphlogi-,tics,  the  man  was  completely  cured  in  five  weeks, 
without  exfoliation  or  the  smallest  operation." 

On  one  point  you  may  naturally  feel  some  hesitation :  You 
see  that  clean  wounds,  as  when  a  trooper  is  cut  to  the  scull  with 
a  sabre,  are  not,  (even  when  the  scull  is  fractured,  or  part  of  it 
sliced  away)  attended  with  that  danger  which  was  once  sup- 
posed ;  but  lracture  of  the  scull  produced  by  a  heavy  blow,  where 
the  bones  are  broken,  perhaps  depressed,  may  be,  nay,  must  be, 
an  injury  of  quite  a  different  nature.  You  are  not  only  to  re- 
frain from  trepaning  fissures,  in  the  absence  of  dangerous  symp- 
toms, but,  if  I  may  advise  you,  even  fractures  very  wide  and 
gaping.  "John  Smith,"  (says  Mr.  Hill  in  his  Book  of  Cases) 
"  when  forty  years  of  age,  had  several  inches  of  the  scalp  torn 
off  by  the  kick  of  a  horse,  and  some  of  the  hair  was  beaten  in- 
wards through  a  long  fracture  of  the  scull,  which  was  so  wide 
that  there  was  no  occasion  for  the  trepan.  He  recovered  in  a 
few  weeks,  and  is  well."  Why  does  Mr.  Hill  announce  this 
fact  in  such  abrupt  familiar  terms,  but  because  he  well  knew 
that  this  was  no  unusual  accident,  that  he  had  often  seen  such 
fractures  of  the  scull  spontaneously  cured  ? 

Even  deep  depressions  and  very  irregular  fractures  heal,  and, 
what  is  'more  rarely  to  be  found,  are  permitted  sometimes  to 
heal,  undisturbed.  The  case  of  James  McCartney,  a  boy  of 
between  five  and  six  years  of  age,  is  of  this  nature  :  '*  He  had 
a  large  piece  of  the  parietal  bone  driven  deep  in  by  a  stone. 
A  few  days  after  he  was  stupid,  dosing,  starting,  and  vomiting  : 
there  was  a  large  tumour  and  obscure  fluctuation  on  the  depres- 


Of  Fractures  of  the  Scu  11.  309 

sion,  owing  to  some  ounces  of  blood  below  the  pericranium  ; 
on  piercing  ol  which,  it  sprung  out  to  about  a  foot's  distance. 
The  incision  was  continued  across  the  depression  and  fissures  : 
to  prevent  su>  h  exfoliations  as  often  happen,  the  scalp  was  in- 
ataittli)  lata  clout  down  again,  with  solt  dossils  only  in  the  wound 
to  keep  it  open.  As  no  bad  s\  mptoms  intervened,  the  fissures 
being  wide  enough  to  allow  a  passage  irom  within  the  scull,  no- 
thing farther  was  done  but  lessening  the  dossils  gradually,  till  it 
heaied,  which  happened  in  a  short  time,  without  exfoliation* 
The  hollow  is  considerable,  and  will  continue  for  life."*  He 
is  in  good  health,  and  at  sea. 

You  will  naturally  say,  What  then  should  we  infer  from  these 
casus  i   Are  we  to  do  nothing  in  fractures  of  the  scull?  Are  the 
instruments  hitherto  appropriated  to  fractures  of  the  scull  to  be 
thrown  aside  ?    The  trepan   is  not  the  instrument  appropriated 
to  fractures  of  the  scull,  but  that  with  which  we  perforate  the 
bone,  when  either  fracture  or  any  other  kind  of  occasion  re- 
quires such  opening  ;  and  ol  all  the  motives  for  using  it,  that  of 
fracture  of  the    scull  is   the  least  lreque.it  :  you  perforate   the 
scull  to  let  out  extravasated  blood,  which  oppresses  the  brain, 
to  open  abscesses  which  could  never  force  its  way  through  such 
resistance,  to  raise  depression,  if  you  will,  but  never  on  account 
merely  of  fracture.      Allow  yourselves  but  to  consider  in  what 
fracture  of  the  scull  differs  irom  that  ot  any  other  bone  :  not  in 
want  ol  circulation  in  the  scull,  you  have  every  proof  that  its 
circulation  is  lively  and  perfect,  since  the  dura  mater  is  detach- 
ed, the  pericranium  scraped  off,  the  bone  itself   bent  from  its 
right  direction,  sometimes  raised  up,  sometimes  depressed,* 
and  yet  it  does  not  die  :  you  see  the  integuments  coarsely  torn 
off  with  a  stone  or  a  carriage-wheel  ;  you  see  the  scull  rough, 
yellow,  and  apparently  void  of  circulation  ;  you  see  every  threat- 
ening appearance  of  caries,   and  would  believe  it  dead  :  often 
the  wound  seems  as  if  a  part  or  the  whole  would  exfoliate,  vet 
in  a  few  days  all  the  naked  part  of  the  bone  begins  to  look  red  ; 
a  fine  velvet-like  down  ot  vivid  granulations  begins  to  appear  in 
spots  and  clouds  upon  the  bone  ;  sometimes  these  granulations 
are,  out   of  mere   wantonness  and  ignorance,  scraped  off,  but 
they  instantly  sprout  out  again  :   what  becomes  of  the  rima  fis- 
sure, or  fracture,  is   never  observed  ;  it  is  covered  in  by  this 
pile  of  granulation  spreading  slowly  over  the  bone,  and  uniting 
it  with  the  integuments.      This  process  I  have  seen  with  admi- 
ration, where  1  could  least  expect  it  to  take  place  ;  in  old  crea- 
tures of  ninety  years  of  age,  very  poor  and  miserable,  and  in 
whom,  along  with  fracture,  the  integuments  had  been  so  man- 

*  Hill's  Cafes,  p.  117. 


310  Of  Fractures  of  the  Scull. 

gled  as  to  slough  off  in  flakes.  It  is  just  such  a  delicate  pile  of 
granulations  that  covers  the  surface  of  the  dura  mater,  when  it 
appears  after  the  operation  through  the  tr«.  pan  hole,  uniting  the 
dura  mater  with  the  integuments  and  with  the  margins  of  the 
perforation.  Those  who  affirm  that  there  is  no  danger  in  tre- 
pan, affirm  of  course  that  there  is  none  in  fracture  of  the  scull, 
for  the  perforation  and  the  fracture  heal  by  one  process,  and 
with  an  equal  pace.  If  this,  which  I  have  observed  mam  times, 
be  the  regular  and  natural  process  of  healing  both  in  the  trepan- 
ed  and  in  the  fractured  scull,  what  apologv  have  we  for  per- 
forating the  scull,  and  tearing  with  levers  all  those  parts  we 
think  suspicious,  or  perceive  to  be  depressed? 

The  motives  assigned  for  making  large  and  frequent  open- 
ings are,  in  case  ot  simple  fracture,  to  prevent  danger  ;  in  case 
of  depressed  fracture,  to  raise   up  the  depression  ;  in  case  of 
extravasation  or  abscess,  to  let  out  the  blood  and  matter  freely. 
But,  are  not  the  smallest  openings  we  can  make   sufficient  to 
give  vent  to  any  suppuration,  as  the  smallest  puncture  is  suffi- 
cient for  the  cure  of  the  largest  abscess  in  any  other  part  ?  Is  it 
possible,  would  it  be  prudent  in  any  case  to  lay  open  all  that  part 
of  the  scull  under  which  blood  is  effused  ?    Though  you  were  to 
work  with  your  trepan  as  industriously  and  unconcernedly  as  a 
button-maker,  or  to  trepan  as  this  Henry  Chadborn  did  twenty- 
seven  times,  you  still  would  never  get  to  the  end  of  your  opera- 
tional'the  extent  of  the  extravasation  were  its  only  limits  ;  I  have 
rarely  seen  a  case  of  extravasation  where  the  cake  ol  blood  did 
not  extend  over  one  entire  hemisphere  !  under  a  whole  parietal 
bone,  and  generally  down  to  the  basis  of  the  scull,  nor  an  abscess, 
but  where  much  of  the  surface  of  the  dura  mater  was  coated 
with  pus  :   I  have  never  had  the  good  fortune  to  perform  or  as- 
sist at  any  operation  in  which  it  was  possible,  had  we  been  so 
extravagant  as  to  design  it,  to  expose  the  whole  coagulum  of 
blood  by  perforations  :   in  short,  what  I  have  observed,  is  this  : 
that,  where,  in  the  case  of  abscess,  we  are  fortunate  enough  to 
be  alarmed  early,  one  perforation  gives  vent  to  the  pus  as  well, 
to  my  apprehension,  as   fifty  :   the   matter  bubbles  out  at  each 
systaltic  motion  or  heaving  of  the  brain  ;  nothing  prevents  it  but 
that  fungus  or  protrusion  ol  the  brain,   which  so  frequentl)  hap- 
pens when  the  openings  are  large.     That  I  may  almost  assure 
you  that,  where  the  openings  are  made  large,  they  never  conti- 
nue long  free,  but  are  plugged  up  by  protrusion  of  the  brain.   In 
the  case  of  extravasation,  which  has  no  certain  limits,  I  have 
always  been  sensible  of  the  folly  of  trying  to  lay  it  all  open,  for 
then  the  limits  of  our  operation  could  only  be  limits  of  the  scull : 
but  after  one  perforation,  when,  by  the  heaving  of  the  brain, 
the  clots  have  rolled  out  of  the  trepan-hole,  as  thick  and  black 


Of  Fractures  of  the  Scull.  311 

as  pitch,  there  succeeds  a  more  fluid  blood,  the    patient  often 
finds  instant  relief,  moves  his  paralytic  side,  raises  his  eyes,  and 
though,  without  being    able  to  speak,  knows  his  friends  ;  from 
day  to  day,  the  blood  by   the  natural  process  of  its  dissolution, 
and  by  a  sort  of  secretion  from  the  surface  of  the  dura  mater,  is 
diluted  and  flows  out.     The  introduction  of  the  probe,  often  to 
the  extent  of  six  inches  in  every  direction,  proves  how  vain  it 
were  to  attempt  laying  open  the  whole  extravasation  :  the   deep 
introduction  of  the  probe  has  probably  suggested    that  practice, 
which  is  mentioned  in  books,  of  making  a  second  and  far  dis- 
tant perforation  as  a  counter-opening,  but  which    I    cannot  ap- 
prove- because  I  have  never  seen  it  necessary  :   the  probe  bent 
and  surrounded  with  a  little  lint,  or  a  long  hair  pencil,   is    very 
useful  in  hooking  out  the  clots,  and   an  injection  ot  tepid  milk 
washes  them  away.     While  the  coagulum  is  thus  resolving,  the 
duia  mater  is  suppurating  and  cleansing  on  its  surface  ;  it  is  at 
last  seen  through  the  trepan  hole  of  a  lively  red,  granulating  and 
bleeding  upon  the  slightest  touch:  then  it  comes  into  close  con- 
tact with  the  lower  surface  of  the   scull,  protrudes   with  gentle 
convexity  through  the  trepan  hole  :  the  gianulations  of  the  inte- 
guments, scull,  and  dura  mater  gradually  auhere,  till  the  whole 
becomes  one  undistinguished  granulated  surface,  where  bone 
cannot  be  distinguished  Irom  fksh.     This  is  the  state  of  mat- 
ters, (with  occas.onal  interruptions  and  variations)  in  the  third 
week,  and  thus  the  opening  closes  and  heals.       I  have  oiten 
found  it  necessary,   from  the  strong  protrusion  of  the  dura  ma- 
ter into  the  trepan  circle,  if  not  through  it,  to  repress  the   dura 
mater  at  each  dressing  with  the  probe  wrapt  in  lint,  in  order  to 
give  exit  to  the  matt,  r  or  blood.* 

This  I  can  most  safely  affirm,  that  wherever  I  have  seen  ca- 
sesc  i  fracture,  whether  simple  or  depressed,  committed  not  in- 
judiciously nor  carelessly  to  nature,  they  have  done  well. 
Wherevtr  I  have  found  the  surgeon  impatient  to  perforate,  in- 
tent on  raising  every  depressed  part  of  the  scull,  careful  to  in- 
clude in  the  circle  of  his  saw  every  suspected  piece  of  bone,  and 
anxious  to  secure  a  tree  evacuation  of  matter  by  large  openings  ; 
I  have  seen  such  tearing  up  of  the  scull,  especially  in  boys,  as  I 
could  not  witness  without  pain,  uniformly  followed  by  protru- 
sions of  the  brain,  and  death.  In  no  other  part  ot  the  body  do 
you  open  abscess,  or  discharge  extravasated  blood  bv  large 
openings  ;  is  the  brain  the  only  part  i.o  be  thus  roughly  treated 

*  In  the  circumftanccs  here  defcribed,  fomc  phyficians  have  ordered  counter- 
openings,  others  have  ufed  leaden  canulas,  grooved  or  guttered  probis,  &c.  to 
conduct  the  matter  or  blood  from  under  the  cranium  :  I  have  never  f<  jund  thefe 
neceffary. 


312  Of  Fractures  of  the  Scull. 

and  exposed  to  the  air,  to  dressings,  and  to  every  thing  that  is 
supposed  to  injure  it  ? 

Are  we  then  to  do  nothing  in  fracture  of  the  scull? — Nothing 
I  believe  which  you  should  not  do  in  fracture  of  any  other  hone 
of  the  body.  Pick  away  the  fragments  of  bone,  lay  the  edges 
of  the  lacerated  scalp  quietly  and  smoothly  togtther,  stitch  them 
that  they  may  lie  in  that  nice  contact  which  is  necessary  to  pro- 
cure adhesion,  but  not  tight  lest  they  inflame  :*  lay  all  smooth, 
nice,  and  close,  dressing  the  wound  daily  and  lightly  that  it 
may  adhere,  which  often  it  does  to  a  miracle,  the  dura  mater, 
trepaned  circle,  and  crushed  bones  and  integuments,  all  conso- 
lidating in  one  firm  scar :  preserve  the  patient  carefully  from 
every  irregularity  or  excess  that  might  cause  inflammation ; 
keeping  him  quiet,  cool,  low  in  diet,  and  without  wine.  Be  as- 
sured that  the  experience  of  a  Wiseman,  and  the  good  sense  of 
Platner  are  not  to  be  despised ;  remember  what  Platner 
affirms,  "  if  there  are  no  bad  symptoms,  there  is  no  occasion 
for  the  trepan."  Adhere  to  this  general  maxim  announced  from 
such  high  authority,  and  it  shall  be  my  care  to  explain  every 
exception  so  fully  as  to  prevent  you,  while  you  avoid  the  fault 
of  hurry  and  impatience,  running  into  any  fatal  error  from  ne- 
glect. You  see  with  what  perfect  confidence  these  celebrated 
men  dressed  up  a  fracture,  and  committed  the  case  to  nature, 
while  men  of  less  experience  or  knowledge  would  have  been  bu- 
sily occupied  in  scraping  every  limb  of  the  fracture,  and  in  ap- 
plying the  trepan  to  each.  But  they  were  emboldened  by  the 
best  of  all  teachers,  experience,  to  act  thus  :  and  whatever  pre- 
judices in  favour  of  operating  you  may  carry  with  you  from 
school,  to  this  opinion  must  you  return  at  last.  I  can  safely 
declare  along  with  O'Haloran  that,  "  in  cases  of  fractures 
of  the  scull,  long  experience  has  convinced  me  that  many  of 
them  require  no  operation."  If  there  be  any  exceptions  to  this 
rule  it  must  be  when  the  fracture  is  accompanied  with  depres- 
sion. 

SECTION    II. 

Of  Fractures  of  the  Scull  with  Depression. 

I  must  seem  then  to  have  admitted  that   "  depression  of  the 
scull  oppresses  the  brain,  and  requires  to  be  raised  up  with  le- 

*  In  fnch  cafes  I  would  not  attempt  completely  to  re-unite  the  integuments, 
becaufe,  ftiould  they  adhere,  it  will  be  frequently  neceffary  to  open  them  to  let 
out  matter.  Inttrpofe  a  fmail  piece  of  lint  between  the  edyes  erf  the  lcalp,  fo  as  to 
prevent  a  complete  re-union,  and  as  loon  as  all  danger  of  bad  fympcoms  is>  vanifhed, 
it  can  be  healed  in  a  few  days.     S. 


Of  Fractures  of  the  Scull  with  Depression.  313 

ver,  or  cut  out  with  the  trephine  :"  Yet  there  is  no  general 
conclusion  I  should  more  unwillingly  allow  :  I  should  be  inclin- 
ed rather  to  reject  the  general  rule  than  to  qualify  it  with  so 
many  perplexing  exceptions  as  it  would  in  my  judgment  reqiure : 
There  are  many  depressions  so  fixed  that  no  force  of  instru- 
ments could  raise  them  ;  so  extensive,  that  to  cut  them  out,  or 
loosen  and  pull  away  each  fragment  of  bone,  would  be  to  open 
half  the  cranium  and  expose  the  brain  to  protrusion,  on  ac- 
count of  imaginary  dangers.  Depressions  seem  many  times 
so  alarming  to  the  surgeon,  that  to  raise  them,  or  cut  them 
out,  he  will  use  the  most  unjustifiable  violence  ;  yet,  though 
he  fails,  and  the  depression  remains,  the  patient,  notwithstand- 
ing this  additional  violence,  survives:  and  many  times  the  de- 
pression, which  has  been  the  subject  of  such  unjustifiable  vio- 
lence, though  verv  conspicuous  while  the  surgeon  is  labouring 
to  raise  it,  is  really  so  slight  as  to  be  invisible  before  the  wound 
is  closed. 

The  striving  to  elevate  depressions  of  the  scull,  while  the 
patient,  far  from  having  any  oppression  of  the  brain,  is  crying 
with  torture,  struggling  and  resisting,  though  it  has  been  long 
esteemed  the  most  meritorious  work  in  surgery,  is  extremely 
censurable,  and  has,  to  my  certain  conviction,  brought  many  a 
patient  to  an  untimely  grave.  "  I  shall  now  (says  O'Haloran) 
remark  on  such  fractures  as  necessarily  require  the  operation  in 
the  first  instance  :  these  are  fractures  accompanied  with  de- 
pression, with  or  without  wounds  :  for  not  to  advert  to  the 
restraint  such  pressure  must  necessarily  cause  to  the  brain,  suf- 
ficient in  itself  to  produce  fatal  effects,  Sec."  This  is  affirm- 
ing, in  its  utmost  latitude,  that  very  mistake  on  which  all  the 
bloody  doings  of  past  and  present  ages  are  to  be  attributed.  "  If 
a  single  operation  (says  Warner)  be  insufficient,  (as  I  have  of- 
ten known  it  to  be)  to  effect  the  elevation  of  the  depressed  bone, 
a  second  and  a  third  must  be  performed,  that  the  surgeon  may 
be  enabled  to  raise  up  every  part  of  the  depressed  bone  ;  which 
rule  must  be  strictly  observed,  otherwise  the  operation  cannot 
be  expected  to  be  attended  with  success,  as  the  bud  rjftcts  of  the 
oppressed  brain  must  remain."  In  every  elementary  book  you 
read  the  same  language,  and  from  everv  lecturer  hear  the  same 
general  conclusion ;  lor,  in  describing  the  scull,  he  assigns  de- 
pression of  it  and  its  fractured  part  intruding  upon  the  brain,  as 
the  principal  occasion  for  using  the  trepan. 

This  passion  for  leaving  nothing  undone  will  naturally  glide 
into  your  minds  ;  for  the  prejudice  of  every  profession  is  in  fa- 
vour of  what  its  art  can  accomplish,  and  in  ours,  this  bias  is  pe- 
culiarly strong  :  trepaning  fractures,  raising  depressions,  and 
making  amnle  openings  for  blood  or  matter,  are  the  surgeon's 

.2  R 


314  Of  Fractures  of  the  Scull  xvith  Depression. 

chief  pride.  But  I  cannot  help  recollecting  the  droll  expres- 
sion of  Permanmus,  who  says,  or  his  translator  lor  him,  "  there 
are  many  persons  who  fondly  imagine  that  boring  a  hole  in  the 
scull  is  an  easy  matter,  and  to  be  done  at  any  time,  whereas  it 
requires  mature  consideration,  a  very  able  head,  and  a  skilful 
hand  to  undertake  it. 

Aware  of  the  deceptions  to  which  you  are  exposed,  I  should 
feel  myself  much  to  blame  did  I  neglect  to  warn  you  of  them. 
You  will  say  within  yourselves,  "  though  it  is  plainly  our  duty, 
and  is  most  natural,  to  leave  a  mere  incision  or  wound,  although 
it  affect  the  scull  itself,  untouched  and  but  lightly  dressed,  since 
we  know  that  wounded  bone  will  re-unite  with  the  soft  scalp  ; 
though  it  be  equally  natural  and  right  to  tit  at  a  compound  frac- 
ture of  the  cranium,  even  where  it  is  much  shattered,  like  a 
compound  fracture  of  a  limb,  by  picking  away  the  loose  bones, 
cleansing  the  wound,  composing  the  soft  parts,  and  laying  all 
smooth  and  close  ;  is  it  equally  natural  or  proper  to  leave  unre- 
duced a  depressed  portion  of  the  cranium,  which  cannot  but 
press  upon  the  brain  ?"  "  Surely,  (you  would  sav),  the  visi- 
ble depression  of  a  piece  of  the  scull  must  be  an  oppression  to 
the  sensorium,  of  the  worst  and  most  dangerous  nature,  be- 
cause it  is  sudden  or  rather  instantaneous,  and  because  it  is 
produced  by  a  firm  and  solid  body:  blood  and  matter  being 
fluid,  may  be  absorbed,  and  thus  time  may  lessen  that  kind  of 
pressure  ;  but  what  can  remove  the  compression  of  a  firm  and 
solid  bone  ?  Are  we  to  remain,  you  would  be  inclined  to  ask, 
unconcerned  spectators,  whilst  our  patient  labours  under  a  visi- 
ble depression  of  the  cranium  r" — These  are  real  difficulties, 
and  must  be  answered ;  and  facts  will  hardly  persuade  you 
when  balanced  against  such  strong  probabilities  :  but  the  whole 
question  shall  be  fairly  laid  before  you  ;  it  is  one  of  those  which 
I  stand  pledged  to  discuss  with  soberness  and  deliberation  ;  it 
is  one  in  which  you  must  learn  to  decide  on  sure  principles, 
since  you  are  about  to  enter  on  that  scene  where  responsibility 
rests  on  each  of  you,  where  you  must  trust  to  your  natural  rea- 
son, not  to  the  dogmas  of  any  teacher,  and  suit  your  practice 
to  the  various  exigencies  of  each  case. 

There  is  a  wide  difference,  in  theory  and  in  fact,  betwixt  the 
oppression  proceeding  lrom  extravasated  blood,  and  that  from 
depressed  bone.  It  is  because  bone  is  firm  and  immovable 
that  its  depression  does  no  harm  !  for  the  pressure  it  causes  is 
permanent,  not  progressive  ;  it  is  fixed  and  complete  at  once  : 
if  the  patient  be  not  struck  insensible  the  moment  the  bone  is 
beaten  below  its  level,  he  never  can  become  so  ;  and  you  will 
find,  by  a  singular  variety  of  proofs,  which  I  am  now  to  lay  be- 
fore you,  that  he  seldom  becomes  insensible.     The  brain  is  ca- 


P.  Stf. 


ng.i.    s 


Fie  . . . 


Ko\  -2. 


i 


Of  Fractures  of  the  Scull  with  Depression.  2 1 5 

pable  of  accommodating  itself  to  any  degree  of  pressure  which 
is  fixed  and  stationary,  and  that  arising  from  a  depression  of 
the  scull  is  so  slight  that  it  can  hardly  be  estimated ;  for  the 
depressed  portion  is  a  very  small  segment  of  a  large  circle  :  the 
broadest  depression  possible  is  not  equal  to  one-tenth  of  the 
whole  convexity  of  the  cranium.  The  smallest  deviation  from 
a  circle  seems  very  great,  and  that  depression  which  is  very  vi- 
sible outwardly,  makes  an  inconsiderable  impression  within : 
the  depressed  portion  of  the  cran.um  is  so  little  off  its  levd,  that 
it  merely  exposes  a  rough  and  rising  edge  never  exceeding  the 
whole  thickness  of  the  bone  :  the  fractured  and  depressed  por- 
tion dips  only  at  the  line  of  fracture,  and  declines  very  gradual- 
ly frotn  the  line  where  it  is  level  with  the  scull  to  the  line  of  its 
greatest  depression:  a  depression  even  of  three  inches  long,  of 
the  parietal  bone,  tor  example,  (Vide  (7/)  figure  1.  of  fractured 
scuils)  declining  gradually  lor  two  inches,  and  terminating  in 
a  depression  of  the  depth  of  a  fifth  of  an  inch,  (i.  e.  the  full 
thicknt  ss  of  the  most  substantial  scull,)  must  produce  an  abridge- 
ment of  its  cavity  inconceivable-  small,  as  is  marked  and  demon- 
strated by  the  dotted  line  (c.  fig.  1.) 

The  slight  effect  that  could,  in  the  worst  depressions,  be 
produced  by  intrusion  of  the  bone,  would  be  to  exclude  from 
the  regular  circulation  within  the  head  a  verj  trivial  proportion 
of  blood.*  But  when  blood  is  poured  out,  the  effusion  is  not 
instantaneous  but  slow  ;  every  time  the  brain  subsides,  i.  e.  at 
each  respiration,  more  blood  exudes  from  the  ruptured  vessels ; 
it  is  injected  betwixt  the  scull  and  dura  mater  by  the  force  of 
the  circulation :  this  internal  haemorrhagy  is  probably  not  com- 
plete at  first,  but  is  renewed  in  paroxvsms  ;  it  is  not  limited  to 
one  spot,  but  is  diffused  over  the  whole  hemisphere  of  the  brain  : 
the  cxtravasated  blood  has,  by  accumulating  and  coagulating,  all 
the  effect  of  a  solid  body  :  nay  more,  as  it  increases  in  quantity, 
in  proportion  as  the  brain  yields,  it  acts  with  the  force  of  a 
wedge,  which  presses  harder  the  deeper  it  is  driven.  Such  is 
the  difference  betwixt  the  injection  of  soft  blood  within  the  firm 
cranium,  and  depression  of  the  scull. 

But  these  are  only  arguments,  which  you  dare  not  trust  to  ; 
you  must  have  proofs  more  relevant  than  these ;  and  the  facts 
I  have  to  display  are  really  singular.  It  having  once  become 
an  acknowledged  maxim,  that  the  surgeon  should  trepan  every 
fracture,  and  elevate  every  slight  depression,  no  one  having  any 
opportunity  of  seeing  a  pure  case  of  depression  where  the  sur- 
geon had  not  been  busv,  it  might    eventually  have  been  very 

•    Is    preflure    upon    the  dura  mafer  nothing,  or  there  is  no  chance  of  that 
rcfiure  caufing  inflammation  of  the  membranes  of  the  brain?     S. 


316  Of  Fractures  of  the  Scull  xvith  Depression. 

difficult  to  prove  that  it  is  safe  to  leave  such  fracture  untouched. 
But  a  thousand  favourable  accidents  have  betrayed  the  im- 
propriety of  this  rash  practice,  and  proved,  in  various  ways, 
that  the  surgeon  has  been  usually  occupied,  and  often  with  ex- 
treme violence,  in  elevating  fractures  which  had  been  better  left 
alone.  Sometimes,  in  the  hurry  and  confusion  of  such  a  bloody 
scene,  a  remarkable  depression  of  the  scull  has  escaped  investi- 
gation, the  patient  has  escaped  the  violence  and  dangers  of  an 
operation,  and  the  surgeon  has  been  sensible  of  the  deep  de- 
pression only  bv  feeling  it  through  the  scalp  when  the  man  was 
well:  Sometimes  relations  and  friends  have  interposed  and  pre- 
vented the  well-intended  operations  of  the  surgeon,  who  has 
protested  against  leaving  a  great  depression  unreduced,  and 
prognosticated  death,  )et  the  patient  has  recovered:  Some- 
times, the  surgeon  having  leave  to  do  his  work,  having  made 
his  perforations  and  pushed  in  his  levers,  has  found  the  depres- 
sion too  deep  and  too  firm  to  be  raised  ;  after  ever)'  justifiable 
and  every  unjustifiable  violence,  he  has  been  unable  to  raise  the 
depression,  and  has  not  dared  to  cut  it  out ;  he  has  left  the  pa- 
tient in  this  desperate  state,  and  yet  seen  him  recover  after  such 
violence,  added  to  the  deep  depression  :  Sometimes  when,  from 
the  foul  air  of  hospitals,  or  the  prevalence  of  epidemic  diseases, 
the  surgeon  has  been  deterred  from  his  favourite  work,  he  has 
discovered,  with  equal  pleasure  and  surprise,  that  "  more  reco- 
ver (to  use  the  words  of  Perusinus)  by  medicines  than  by  the 
knite  and  the  saw."  Indeed,  the  conclusion  against  the  pro- 
fession and  its  general  propensity  to  operate,  in  mere  injuries 
of  the  scull,  is  stronger  than  I  believe  you  are  aware.  I  know 
that  if  you  had  seen  with  me  the  precipitation  and  violence  with 
which  depressions  of  the  scull  are  torn  up,  and  the  miserable 
consequences  arising  from  large  openings,  both  your  reason  and 
your  feelings  would  revolt  against  the  practice. 

"  I  chanced  once  (says  Platner)  to  be  called  to  the  assistance 
of  one  who  had  fallen  from  the  third  story  of  a  house,  and  lay 
quite  torpid  and  oppressed,  as  in  a  deep  sleep.  The  surgeon, 
having  shaved  his  head,  found  there  a  very  deep  and  wide  de- 
pression of  the  scull.  While  we  were  wondering  how  the  scull 
could  be  thus  deeply  impressed  by  the  fall,  the  integuments  be- 
ing but  slightly  ruffled,  the  man  recovered  his  senses  in  a  for- 
tunate hour ;  alarmed  at  the  proposal  of  an  operation,  he  told 
us  that  the  impression  we  had  observed  was  of  no  importance  ; 
he  had  it  from  his  childhood ;  and  yet  had  lived  in  perfect  health  : 
he  recovered  without  assistance."  We  are  at  a  loss  to  conceive 
how,  even  whert  the  integuments  remain  entire,  so  wide  a  frac- 
ture, and  so  much  depression,  can  be  consolidated  without  any 
ill  symptoms ;  but  several  cases,  which  I  have  myself  witnessed, 


Of  Fractures  of  the  Scull  with  Depression.  317 

make  the  process  quite  familiar  to  me  :  and  one  related  by  Bb- 
tallus  I  think  particularly  worthy  of  your  notice  :  lk  Some"  (says 
Botallus)  "  will  very  readily  acknowledge  -that  bones,  tractured 
without  an  external  wound,  are  easily  cured  in  other  parts  of 
the  body,  while  they  deny  the  bones  of  the  scull  to  be  thus  cured : 
I  will  relate  plainly  what  I  have  myself  seen.  While  I  prac- 
tised surgery,  a  boy,  as  I  guess  about  seven  years  oi  age,  fell 
from  a  gallery  twelve  feet  high,  and  pitched  directly  upon  his 
head  ;  the  parietal  and  part  oi  the  Irontal  bones  were  so  frac- 
tured that  you  could  teel  distinctly  the  several  fractured  pieces, 
yet  the  skin  (he  having  fallen  upon  a  flat  pavement)  was  not 
wounded,  nor  even  the  hair  ruffled.  When  called,  1  was  alto- 
gether confounded  at  finding  such  a  fracture,  the  boy  speaking, 
and  in  his  perfect  senses,  with  only  a  slight  acceleration  of  pulse, 
(he  was  however  insensible  at  first,  and  had  vomited  up  his 
dinner  along  with  some  bile)  a  thousand  thoughts  passed  across 
my  mind,  while  those  I  had  cent  to  the  apothecary's  were  re- 
turning with  some  medicines.  I  was  for  some  time  irresolute 
whether  to  make  an  incision  and  pick  away  the  lractured  bones, 
or  to  leave  the  parts  entire  :  at  last  I  resolved  on  this  more  lenient 
plan.  In  place  of  making  an  incision,  I  covered  the  whole  head 
with  Armenian  Bole,  Myrtle  Berries,  and  Rose  Leaves,  mixed 
with  vinegar  and  white  of  eggs  ;  and  this  astringent  application 
I  used  during  four  days.  The  boy  perfectly  recovered  without 
incision  ;  he  lived  many  years  ;  and,  though  I  do  not  recollect 
his  name,  I  have  reason  to  believe  he  is  still  alive.1'*  This  in- 
genuous avowal  of  Botallus,  that  he  was  altogether  confounded 
at  feeling  such  a  fracture,  and  that  a  thousand  thoughts  had  fleet- 
ed across  his  mind,  makes  the  case  highly  interesting  :  we  arc 
conscious,  from  the  conclusion  of  the  case,  how  dangerous  these 
thoughts  were  to  the  patient,  and  must  feel  that  when  they  pre- 
sent themselves  to  our  imagination,  they  should  be  resisted. 

Parents  have  often,  with  seeming  perverstness,  refused  as- 
sistance in  the  last  extremity,  and  even  the  earnestness  with 
which  it  is  offered,  is  a  motive  for  refusing  it  :  despair  makes 
them  unwilling  to  disturb  the  last  moments  of  their  child,  which, 
being  left  undisturbed,  recovers  ;  what  the  fate  of  such  a  child 
might  be  if  trepaned,  must  ever  remain  doubtful. 

i  was  called  once  to  a  child,  whose  circumstances  seemed  so 
very  desperate  that  I  urged  the  parents  to  allow  of  an  operation, 
which  fortunately  they  refused.  **v  This  little  girl,  about  twelve 
years  of  age,  was   playing  with  her  school  companions  on  the 

*  I  cannot  agree  with  Mr.  Bell  in  the  propriety  of  the  practice  here  commend- 
ed, although  the  patient  recovered.  Though  the  general  argument  is  correct,  that 
it  is  not  nccclfr.ry  to  trepan  every  depreffion,  the  doctrine  muft  not  be  pufhed  too 
ijir.     S. 


318  Of  Fractures  of  the  Scull  with  Depression. 

very  steep  declivity  of  the  Earthen  Mound  :  two  of  them  were 
running,  hand  in,  hand  when  this  little  girl,  losing  the  hand  of 
her  play-fellow,  rolled  from  top  to  bottom  of  the  Mound,  with 
continually  increasing  velocitv,  till  at  last  she  pitched  with  her 
head  full  against  a  low  wall,  at  some  distance  beyond  the  bot- 
tom. She  was  carried  home  in  a  chair,  stiff  and  motionless, 
perfectly  pale,  and  without  pulse  ;  she  hardly  breathed  ;  and 
we  had  no  evidence  of  her  being  alive  but  a  slight  degree  of 
warmth,  which,  after  cutting  off  her  clothes,  (for  she  was  stiff  as 
well  as  motionless)  was  difficultly  increased  to  a  natural  warmth. 

"  From  this  time  she  lay  in  a  deadly  stupor,  with  a  blemish 
on  one  temple  ;  there  was  no  tumour,  but  flat  integuments, 
through  which  I  imagined  I  could  feel  a  fracture  and  depres- 
sion of  the  parietal  bone,  while  the  signs  of  accompanying  ex- 
travasation seemed  very  unequivocal:  her  limbs  were  stiffened  ; 
her  whole  frame  in  a  sort  of  tonic  or  permanent  convulsion : 
her  jaws  firmly  and  immovably  locked  ;  her  extremities  cold, 
and  her  pulse  oppressed  and  intermitting.  In  this  state  she 
lay  for  four  or  five  days  immovable  ;  hardly  was  a  tea-spoonful 
of  wine  and  wattr  admitted  betwixt  her  teeth,  which  were  firm- 
ly and  immovably  closed.  I  was  then  p<  rsuaded,  and  remain 
so,  though  she  happily  recovered,  that  there  was  extravasation 
under  the  parietal  bone  ;  and  my  persuasion  was  so  great  that, 
on  the  fourth  and  fifth  days,  I  solicited  her  parents  to  allow  of 
an  incision,  and  even  spoke  to  the  clergyman,  who  was  called 
to  them  at  this  dismal  time,  to  persuade  them  to  consent.  On 
the  sixth  day  she  yawned  widely,  and  from  that  moment  her 
jaws  were  loosened  :  we  could  now  put  in  a  few  spoonfuls  of 
wine  and  water,  and  give  purgative  medicines  :  but  she  lay  still 
and  dead,  in  the  most  profound  stupor  I  ever  witnessed.  She 
began  in  the  second  week  to  stir  the  limbs  of  one  side  a  little, 
and  in  two  days  more  she  stirred  sometimes  an  arm,  some- 
times a  leg,  of  the  opposite  side  :  then  her  eyes  opened  at  times, 
and  she  began  to  mutter  and  speak  ;  but  it  was  the  fifteenth  day 
before  this  low  muttering  came  on  ;  and  then,  and  till  the  twen- 
tieth, though  her  eyes  were  open,  we  had  unquestionable  evi- 
dence that  she  could  not  see  ;  a  candle  approached  to  the  eye 
gave  no  sensation,  the  eye  did  not  follow  it,  nor  were  the  eye- 
lids closed  as  expressive  of  impatience  of  light,  and  the  pupil 
was  as  much  dilated  as  if  she  had  lain  in  a  dark  place. 

"  She  now  became  restless,  the  struggling  of  the  limbs  of  both 
sides  increased,  she  put  out  her  hands  and  stretched  her  limbs 
with  a  sort  of  trembling,  and  muttered  perpetually.  On  the 
fourth  week,  she  came  to  swallow  more  easily,  to  take  the  drink 
which  had  hitherto  been  poured  into  her  mouth,  and  to  speak 
rationally.     She  next  sat  up  in  bed,  was  raised  into  a  chair,  and 


Of  Fractures  of  the  Scull  with  Depression.  319 

gradually  recovered  her  senses  and  her  strength.  She  was  then 
able  to  be  led  about  the  room,  but  two  months  elapsed  before 
she  could  be  said  to  walk  :  even  then  she  was  neve r  left  alone, 
nor  walked  unsupported.  She  was  led  about  the  whole  sum- 
mer in  this  weakly  condition  ;  but  is  now  a  strong  and  healthy 
girl."* 

But  the  practice  of  those  who  believe  it  to  be  their  duty  to 
scrape  every  fissure,  and  raise  every  depression,  who  are  ever 
ready  to  go  to  rvork  with  their  instruments,  affords  the  com- 
pletest  proof  of  the  improvidence  of  such  practice  ;  and  we  find 
practical  errors  narrrated,  by  the  best  modern  surgeons,  with  a 
non  chalance,  and  want  of  consciousness,  altogether  astonishing. 
u  I  cured  a  boy,  (says  Marchetti)  of  seven  years  of  age,  who, 
from  the  kick  of  a  horse  in  the  forehead,  had  a  very  remarka- 
ble depression,  which  neither  tripod  nor  lever  could  any  way 
elevate  ;  but  there  being  a  fissure  in  one  part,  I  betook  myself 
to  the  rugin,  dilated  the  fissure,  so  that  the  serous  humour  had 
leave  to  exude,  while  the  medicines  had  leave  on  the  other  hand 
to  penetrate  to  the  dura  mater,  so  that  in  the  course  of  forty 
days,  flesh  being  regenerated  in  the  fracture,  the  wound  was 
safely  and  soundly  cured."  But,  had  the  celebrated  Marchetti 
been  permitted  (as  it  was  a  wonder  his  authority  did  not  pre- 
vail) to  trepan  this  little  boy,  to  tear  up  the  scull  with  his  tri- 
pods and  levators,  it  is  possible  at  least,  that  even  after  such  vi- 
olence, he  might  have  survived,  and  then  the  operation  and  the 
operator  would  have  been  applauded  for  saving  the  patient's  life; 
and  had  the  elevation  of  the  bone  been  accomplished,  though 
with  every  circumstance  of  violence  and  rudeness,  the  operation 
would  have  become  memorable.  Such  a  case  is  that  recorded 
by  Mr.  O'Haloran,  in  which  everv  principle  of  sound  surgery 
was  violated.  He  found  a  child  with  a  depression  of  the  scull 
with  the  integuments  entire,  and  the  senses  quite  composed  and 
perfect,  when,  without  any  motive  but  his  own  fears,  he  cut 
open  the  scalp  ;  and  that  depression,  which  had  hitherto  done 
no  harm  to  the  child,  he  elevated  in  the  rudest  and  most  shock- 
ing manner,  making  no  fewer  than  four  perforations  in  the  scull 
of  the  child,  thrusting  into  each  hole  a  levator,  and  to  his  four 
levators  he  had  two  surgeons,  who  seem  to  have  had  as  little 
tenderness  as  himself,  for  they  pulled  with  might  and  main, 
till  the  depressed  bone  rose  with  a  sudden  spiing.  But  here  is 
his  own  narrative. 

11  A  girl,  about  seven  years  ofag*  received  a  severe  fracture, 
with  profound  depression,  on  the  left  parietal  bone  ;  the  i/ittgu- 
mentswere  entire,  the  girl  quite  composra  and  sensible,  but  the 

•  This  cafe  (hews  what  may  happen,  b:it  would   M;\  Bell  himfelf  prognoflicaic 
a  Cmilar  iflue,  under  fimilar  circumilances  ?     S. 


320  Of  Fractures  of  the  Scull  with  Depression. 

depression  was  so  deep  that  it  could  contain  a  very  synall  egg. 
Su  h  was  her  situation  when  brought  to  me  hair  an  hour  alter 
the  injun.  Seeing  that  it  would  require  three  or  tour  crowns 
of  the  trephine  to  raise  this  extended  fracture,  I  requested  of 
Mr.  Wallace,  a  military  surgeon,  and  Mr.  Pierce,  to  assist 
me  in  this  charitable  work.  1  removed  all  the  intt  guments,  wi- 
ped away  the  blood,  and  whilst  these  gentlemen  with  their  fin- 
gers made  compression  over  the  bleeding  vessels,  I  began  to 
operate  on  the  inferior  parts  of  the  bone.  I  then  commenced  a 
second  on  the  upper  part,  and  in  a  line  with  this ;  but  two  eleva- 
tors, though  acting  at  the  same  time,  had  no  effect  on  the  de- 
pression. Two  more  crowns  were  then  applied  to  the  sides  of 
the  bone,  and  parallel  to  each  other.  Four  levers  ucting  in  con- 
junction, it  astonished  me  to  see  with  xvhat  a  sudden  spring  the 
depressed  parts  resumed  their  former  station.  Notwithstanding 
the  great  extension  of  this  fracture,  the  loss  of  covering,  and  of 
the  bone  itself,  by  four  crowns  of  the  trephine,  this  girl  never 
after  had  the  smallest  untoward  symptom." 

Is  it  by  such  narratives  and  such  proceedings  that  the  good  re- 
pute of  surgery  is  to  be  preserved  ?  by  no  means :  we  should  at 
first  sight  be  inclined,  both  from  the  violence  used  in  raising 
this  depression,  and  from  the  success  of  the  operation,  to  as- 
cribe the  patient's  safety  to  the  intrepiditv  of  the  surgeon  ;  but 
what  should  we  have  said  of  Mr.  O'Haloran's  practice  had  he 
miscarried,  and  been  unable,  with  his  military  assistants,  his 
pair  of  surgeons  and  double  pair  of  levators,  to  raise  the  depres- 
sion, and  yet  the  j>atient,  after  all  kinds  of  violence  being  added 
to  the  depression,  had  lived  ?  There  is  not  in  the  narrative  of 
this  case*  any  shadow  of  proof  that  the  patient  was  saved  by  this 
mode  of  operation  ;  the  child  was  composed  and  sensible,  had 
no  bad  s\  mptoms,  and  would  {might)  have  had  none  to  the 
very  end  of  the  cure,  had  she  been  left  alone  :  it  proves  merely 
what  is  but  too  surely  true,  that  often  the  patient  survives  the 
most  imprudent  things  the  surgeon  can  do. 

I  will  now  produce  you  evidence  that  I  put  no  worse  con- 
struction upon  this  case  than  it  should  bear  ;  it  will  prove  to 
you,  that,  even  where  the  depression  is  broad  and  deep,  where 
convulsions  have  ensued,  where  the  surgeon,  alarmed  at  these 
signs  of  danger,  has  made  his  incisions  and  his  perforations, 
and  tried  ineffectually  to  raise  the  depression,  the  patient  has 
survived  both  the  depression  and  the  ineffectual  operation, 
which  must  ever  be  a  violent  one.  Mr.  Hill  undertook,  in  an 
unfortunate  hour,  the  following  operation.  u  A  boy  of  the 
name  of  Carson,  between  five  and  six  years  of  age,  by  the  kick 
of  a  horse,  had  a  long  piece  of  the  cs  frontis  beat  in  fat  :  he 
slept  souud,  as  the  people  termed  it,  about  two  hours,  and  then 


Of  Fractures  of  the  Scull  with  Depression.  321 

fell  into  strong  convulsions.  The  extravasation  was  so  great 
externally,  that  the  precise  quantity  of  the  bone  depressed  could 
not  be  determined,  till  the  blood  was  discharged  by  a  horizon- 
tal incision  along  the  depression,  by  which  I  discovered  it  to 
be  of  an  elliptical  form,  extending  above  two  inches  across  the 
forehead,  and  above  the  right  sinus  frontalis,  with  a  fissure  all 
round  it.  The  external  discharge  not  relieving  him,  showed 
that  the  perforation  would  be  necessary  ;  and,  therefore,  after 
allowing  the  first  incision  to  bleed  some  ounces,  it  was  stopped 
by  dry  dossils.  Being  determined,  lor  the  reasons  formerly 
given,  not  to  touch  the  depressed  part,  unless  some  symptoms 
should  afterwards  make  it  necessary ,  I  continued  the  incision 
till  there  was  room  for  perforating  a  quarter  of  an  inch  from  the 
fissure,  at  the  right  end  of  the  depression.  The  bleeding  was 
troublesome  ;  but  no  arteries  required  to  be  stitched,  but  were 
stopped  by  dossils  dipt  in  ardent  spirits,  and  applied  tor  half  an 
hour.  After  which  just  as  much  of  the  pericranium  was  remo- 
ved as  was  necessary  to  admit  the  smallest  head  of  the  trepan. 
The  connecting  blood  vessels  betwixt  the  dura  mater  and  scull 
were  broken  through  the  whole  extent  of  the  depression,  being 
at  least  two  inches  ;  for  so  far  I  introduced  the  levator,  without 
opposition,  and  attempted,  with  a  good  deal  of  force,  to  raise 
it ;  but  in  vain. — After  the  extravasated  blood  was  discharge  d, 
three  intersected  stitches  were  put  into  the  first  incision  above 
the,  depression,  and  it  united  in  a  few  days  ;  and  the  rest  of  the 
skin  healed  in  four  weeks,  without  the  intervention  of  any  bad 
symptom — He  is  well,  1771;  and  the  depression,  owing  to 
his  youth,  is  so  expanded  by  natural  growth  and  callus,  as  not 
to  be  much  perceived." 

If  any  thing  could  repress  the  presumption  of  a  man  of  an 
adventurous  temper,  this  must :  to  propose  an  operation  under 
protest,  that  it  was  the  only  possible  means  to  save  the  patient's 
life  ;  to  attempt  that  operation  ;  to  see  the  patient  survive  the 
depression  which  had  been  declared  fatal,  unhurt  by  the  addi- 
tional violence  of  incisions,  trepans  and  levers  5  Surely  these 
facts  should  lead  the  surgeon,  who  had  been  in  the  habit  of  ele- 
vating inexorably  every  slight  depression,  into  a  new  train  ot 
thought. 

The  prominent  points  ot  this  case  of  Mr.  Hill's,  stand,  in 
common  sense  and  plain  argument,  thus:  First,  the  depression, 
while  it  continues,  does  no  harm,  the  boy  being  in  his  entire 
senses  :  Second,  the  surgeon  is  so  alarmed  at  the  very  appear- 
ance of  depression,  that  he  labours  with  every  degree  of  vio- 
lence to  raise   it,  his  own   reputation,  as  well  as  the  patient's 

2S 


322  Of  Fractures  of  the  Scull  with  Depression. 

health,  seeming  to  be  at  stake  :  Thirdly,  abandoning  the  opera- 
tion, and  leaving  the  depression  as  h<_  found  it,  he  puts  three 
stitches  in  the  wound,  and  so  the  integuments  unite  over  the 
depression  in  a  few  days  :  Fourthly  the  patient  is  no  sooner 
recovered,  and  the  wound  healed,  than  the  depression,  which 
appeared  so  formidable  to  the  surgeon  when  seen  and  felt  at  the 
bottom  of  a  bloody  wound,  the  depression,  to  raise  which  he 
willingly  risked  every  thing,  disappears  spontaneously,*  so  little 
is  it  off  the  level.f 

I  will  now  relate  the  circumstances  of  an  operation  in  which 
I  was  a  party  ;  where  although  I  was  obliged  to  be  a  witness 
and  unwilling  assistant  in  much  mangling,  I  saved  the  man  a 
great  deal  more.  There  was,  along  with  a  wide  fracture  of  the 
parietal  bone,  through  which  the  extravasated  blood  was  seen, 
a  slight  depression  of  it  at  one  corner  of  the  fracture  :  the  trepan 
was  applied  :  the  extravasated  blood  rolled  out :  the  duty  of 
the  surgeon  was,  according  to  my  apprehension,  completely 
fulfilled  ;  but  he  was  urged  by  others  who  were  present  to  raise 
this  depression,  with  a  degree  of  earnestness  which  left  him  en- 
tirely responsible  for  the  consequences.  I  most  unwillingly 
witnessed,  but  would  not  consent  to  assist  in  this  part  of  the 
operation.  After  extreme  violence  (for  always  the  violence  is 
extreme  where  the  surgeon  works  till  he  is  foiled)  it  was  found 
altogether  impossible  to  elevate  the  depressed  bone.  The  ope- 
rator was  now  called  upon,  under  the  same  responsibility,  to 
make  one,  or,  if  necessary,  two  perforations,  on  the  sides  of 
the  depressed  portion,  to  raise  it.  I  saw  plainly  that,  if  the 
operation,  now  protracted  for  an  hour,  should  continue  still 

*  Thefe  are  not  folitary,  nor  even  rare  cafes.  Read  the  following  from  Mr. 
Hill.  "  February  24,  1750-  Mr.  Robert  Rae,  when  a  young  man,  fell  hack- 
ward  from  his  horfe  on  a  rock,  about  twelve  miles  from  Dumfries.  By  his  foot 
flicking  in  the  ftirrup,  he  was  dragged  fome  way,  till  the  girth  broke,  and  left 
him  with  his  head  betwixt  two  flones  in  a  rill  of  water,  where  he  would  foon 
have  been  fuffocated  had  not  a  fliepherd  boy  drawn  him  out. — A  large  piece  of  the 
left  parietal  bone  was  driven  in  backward  to  the  lambdoid  future,  with  a  fifiure  in 
the  right  parietal'forward,  being  like  a  fhepherd's  crook  :  notwithstanding  the  lar- 
ger deprefiion,  there  was  no  extravafation  ;  nor  -would  the  bones  rife,  though  a  -very 
great  force  -was  employed ;  but  they  exfoliated  like  the  former,  and  the  aperture  be- 
ing wider,  the  protrufion  was  greater.  The  cicatrix  continued  foft  for  three  years, 
when  it  oflified  completely. 

f  Mr.  Bell's  triticifms  on  Mr.  Hill's  operation,  if  the  cafe  is  entirely  related, 
do  not  appear  to  be  altogether  correct.  He  fays"  the  boy  was  in  his  entire  fenfes,'' 
when  Mr.  Hill  fays  "  he  was  in  flrong  convulfions."  Although  the  deprenx  J  bone 
was  not  elevated,  yet  the  extravafated  blood  was  difcharged  ;  a  circumftance  of  no 
flight  importance.  Mr.  Hill  fays,  that  "  owing  to  natural  growth  and  callus," 
which  implies  confiderable  length  of  time,  "  the  deprefiion  was  not  much  perceived" 
and  not  that  it  difappeared  when  the  boy  recovered.     S. 


Of  Fractures  of  the  Scull  xvith  Depression.  323 

another  hour,  the  man  would  be  carried  off  delirious  ;  that  it 
the  scull  was  widely  opened  by  two  perforations,  and  by  the 
tearing  away  the  depressed  bone,  his  chance  tor  life  was  very 
slight.  I  said  across  to  the  surgeon,  that  if  he  would  permit 
me,  I  should  most  willingly  take  the  responsibility  upon  myself. 
On  his  consent,  I  put  aside  the  busy  fingers  that  were  search- 
ing tor  depressions,  clapped  a  piece  of  lint  on  the  dura  mater, 
and  conveyed  him  to  bed,  where  he  mended  daily  and  became 
a  very  stout  and  healthy  man. 

The  bloody  decrees  of  the  surgeon  against  all  who  have  de- 
pression of  the  scull  are  never  so  absolutely  suspended,  as  where 
the  ill  constitution  of  the  air  in  a  great  hospital  is  known,  by  the 
experience  of  centuries,  to  destroy  all  those  who  suffer  opera- 
tions on  the  head.  Under  this  imperious  necessity  was  Des- 
sault,  surgeon  of  the  Hotel  Dieu,  who,  during  his  adminis- 
tration, declined,  even  in  the  most  urgent  circumstances,  to 
perform  the  operation  of  trepan. 

Dessault's  clinical  practice,  when  he  merely  allowed  the  pa- 
tients to  lie  undisturbed  and  quiet,  with  a  poultice  to  the  frac- 
tured and  depressed  scull,  and  a  dose  of  calomel  to  move  the 
bowels,  exhibits  a  splendid  series  of  examples  of  what  nature, 
undisturbed  by  partial  operations,  will  do  ;  and  taught  Des- 
sault  himself,  and  proved  to  the  profession,  how  great  a  pro- 
portion of  those  who  are  trepaned  would  live  without  the  help 
of  surgery  :  for  many  recovered  after  lying  long  in  a  state  of 
stupor,  accompanied  with  svmptoms  every  way  alarming,  such 
as  would,  in  any  other  circumstances,  have  induced  Dessault 
or  any  surgeon  to  have  trepaned. 

But  Dessault,  who  was  too  much  inured  to  bloodv  scenes  to 
tear  operating,  and  too  indifferent  to  the  reputation  of  being  an 
operator  to  feel  any  thing  of  the  passion  for  cutting  and  trepan- 
ing,  tried,  for  the  first  time,  the  great  and  important  experi- 
ment of  leaving  his  patients  having  fractures  and  depressions 
of  the  cranium,  at  quiet  in  their  beds.  Among  others,  one  Jo- 
seph Gautier's  condition  was  in  every  sense  interesting,  but  es- 
pecially in  the  slow  absorption  of  that  general  suffusion  of  blood, 
which  we  must  presume  to  have  taken  place  in  the  brain  after  so 
violent  a  concussion  as  he  seems  to  have  suffered,  and  the  gra- 
dual recovery  of  his  senses,  proportioned  in  all  likelihood  to 
that  absorption,  and  accompanying  it  step  by  step;  "Joseph 
Gautier,  a  hale  young  man,  twentv-three  years  of  age,  was 
found  in  the  morning  under  a  window,  which  he  was  accustom- 
ed to  scale  when  late  abroad,  lying  in  a  state  of  stupor,  and  ba- 
thed in  his  blood,  which  streamed  from  his  mouth  and  nostrils, 
and  from  his  left  ear.  When  he  was  brought  from  his  village, 
a  few  miles  distant  from  Paris,  into   the  Hotel  Dieu,   he  was 


324  Of  Fractures  of  the  Scull  with  Depression. 

still  bleeding  from  the  mouth  and  nostrils,  and  insensible  ;  the 
body  cold,  the  face  deadly  pale,  and  the  pulse  small  and  con- 
tracted. On  his  head  were  many  marks  of  contusion  ;  and 
one  ovtr  the  lower  and  fore  part  of  the  parietal  bone,  was  ac- 
companied with  a  depression,  deep  in  the  centre,  and  rising  to- 
wards each  side.  The  clavicle,  which  was  also  fractured,  be- 
ing set  and  bandaged,  the  head  was  wrapped  in  a  large  poul- 
tice :  next  day  he  was  better  ;  the  poultice  was  continued,  and 
he  was  bled  in  the  foot  ;  and  in  the  evening  his  senses  in  some 
degree  returned.  On  the  sixth,  he  began  to  articulate,  but  in- 
distinctly. Bv  the  seventh  his  senses  were  restored  ;  his  taste, 
smell,  and  touch  were  perfect,  but  his  vision  somewhat  impair- 
ed :  he  heard  also  imperfectly  ;  and,  in  respect  to  his  intellect, 
the  faculty  of  memory  seemed  much  weakened  ;  he  could  bv  no 
means  recollect  whence  he  came.  He  had  no  pain  :  it  was  on 
the  tenth  day  that  he  first  rose  and  walked  :  on  the  fourteenth, 
he  walked  abroad  upon  the  bridge,  and  took  his  airing  there 
daily,  till  the  twentieth,  when,  the  fractured  clavicle  being  re- 
united, the  bandages  were  undone.  His  memory  mended  dai- 
ly ;  his  hearing  became  more  acute  ;  his  eyes  gained  strength, 
but  still  the  pupils  remained  dilated  somewhat  wider  than  in  the 
natural  state,  and  the  scull  remained  manifestly  depressed.  On 
the  twenty-seventh,  he  was  carried  into  the  hall  at  lecture,  and 
shewn  to  the  pupils :  this  was  before  he  was  dismissed.  At 
the  end  of  three  weeks,  he  returned  to  show  himself,  his  sen- 
ses heing  entirely'  restored,  and  his  memory  perfect :  the  pupils 
of  his  eyes  had  recovered  nearly  their  natural  smallness,  except 
that  the  pupil  of  the  left  eye  continued  a  little  wider."* 

In  this  case,  when  about  the  third  day,  the  bumpy  swelling 
and  ecthymosis  began  to  subside,  they  felt  the  fracture  and  de- 
pression very  distinctly,  the  fracture  being  of  a  circular  form, 
about  two  inches  and  a  half  in  diameter,  with  one  edge  more 
raised  than  the  other  ;  and  after  his  recovery  it  was  still  more 
plainly  felt. 

"  The  invariably  fatal  consequences  of  using  the  trepan  in 
the  Hotel  Dieu,  deterred  Mr.  Dessault  from  using  it  on  this 
occasion  ;  nor  had  he  any  reason  to  repent  of  his  resolution. " 
Even  when  the  depression  seems  to  produce  the  worst  signs  j 
when  the  patient  bleeds  from  the  nose  and  ears,  and  lies  insen- 
sible ;  when  his  senses  were  not  merely  stunned  and  shocked, 
but  so  materially  injured  that  they  recover  slowly,  it  is  safe  to 
leave  the  depression  untouched  ;  to  trepan  where  there  are  no 
such  signs  would  be  destruction.  Mr.  Abernethy  u  had  a  man 
brought  to  St.   Bartholomew's,  who  was  hit  on   the  forehead 

*  Default's  Chirurgical  Journal,  Vol.  i.p.  tj. 


Of  Fractures  of  the  Scull  with  Depression.  325 

with  a  brick :  the  frontal  bone  was  fractured  half  an  inch  above 
the  orbit;  the  fracture  measured  two  inches  in  length,  and  the 
upper  portion  of  the  brow  was  depressed  about  the  eighth  of  an 
inch.  He  was  not  even  stunned  by  the  blow,  and  walked  to  the 
Hospital  without  assistance,  complaining  only  of  soreness  in  the 
wounded  integuments.  He  was  bled  ;  was  confined,  much 
against  his  inclination,  to  a  scanty  and  liquid  diet,  and  was  pur- 
ged everv  second  day.  This  patient  did  not  experience  any  ill- 
ness, and  the  wound  soon  healed."  But  had  Mr.  Abernt  thy 
been  a  surgeon  ot  the  complexion  I  have  sometimes  ventured 
to  describe  ;  had  the  patient  been  confined,  much  against  his 
inclination,  to  an  operation-table,  and  trepantd,  there  is  little 
doubt,  I  think,  how  it  would  have  fared  with  him. 

But  this  is  the  difference  betwixt  the  proceedings  of  a  man  of 
sense  and  experience,  and  a  man  of  theory.  There  has  been 
too  much  of  surgery!  A  master  in  surgerv  can  look,  calmly 
and  composedly,  on  that  di  pression  upon  which  a  novice  would 
instantly  fasten  his  levers  ;  he  can  sec  the  scalp  whirled  off  from 
both  sides  of  the  scull  ;**  the  parietal  bones  laid  bare  ;   the  tem- 

*  "  A  lad,  feventeen  years  of  age,  had  his  head  preffed  between  a  cart  wheel 
and  a  poft  ;  by  which  accident  the  fcalp  on  both  fides  was  turned  downwards,  fo  as 
to  expofe  the  lower  half  of  the  parietal  bones,  the  fquamous  part  of  the  temporal, 
and  alfo  part  of  the  frontal  and  occipital  bones;  about  a  quarter  of  the  cranium  be- 
ing thus  denuded  of  its  coverings.      I  he  periofteum  was  in  fevcral  places  ftript  off 

from  the  fcull,  the  fcalp  much  bruifed,  and  the  pnflcrior  and  inferior  angle  of  the  left 
parietal  bone  "was  beaten  in.  The  deprcfied  portion,  which  Was  vifible,  -.vat  an 
inch  in  length,  and  more  than  the  eighth  oj  an  inch  belov)  tbe  level  of  the  cranium  ;  but 
the  fracture  extended  along  the  lquamous  part  of  the  temporal  bone,  towards  tbe 
bafis  of  the  fcull  .  it  could  not,  however,  be  traced,  as  the  temporal  mufclc  had  not 
been  removed  from  that  part  by  the  injury.  The  fcalp  being  eleanfed,  was  repla- 
ced, retained  in  its  fituation  by  flips  of  fticking-plafter,  and  a  flight  pi  clfure  by  ban- 
dage, was  applied.  The  boy  teas  perfectly  fenftble,  his  fi./fr  regular,  and  not  quickened. 
He  had  bled  considerably  from  the  temporal  artery,  which  bad  been  divided  by  the 
accident  :  eight  ounces  of  blood  were,  however,  taken  from  his  arm  ;  and  fonie 
purging  medicine  was  adminiltered  next  morning,  which  procured  three  or  four 
ftools.  The  next  day,  (Friday)  his  pulfe  beat  nearly  120  in  a  minute;  his  fkin 
was  hot  and  dry  ;  and  he  complained  ot  pain  in  his  forehead.  '1  welve  ounces  of 
blood  were  taken  away,  and  four  grains  of  pulvis  antimonialis  ordered  to  be  given 
three  times  a  day.  On  Saturday,  the  former  fymptotns  ftill  continued,  and  were 
rather  increafed.  The  antimonial  powder  made  him  Gck, or  at  lead  increafed  his 
difpofition  to  be  fo.  Fourteen  ounces  more  of  blood  were  taken  from  him  ;  the 
vibratory  feel  of  his  pulfe  not  being  altered  until  that  quantity  was  taken  away  : 
the  blood,  on  (landing,  appeared  very  buffy.  His  fkin,  notwithftanding  all  this, 
ftill  remained  extremely  dry  ;  fome  antimonial  wine  was  given,  which  produced 
vomiting.  On  Sunday,  his  pulfe  was  evidently  lowered  by  the  evacuations  he  had 
undergone,  but  it  was  ftill  quick  and  fufficicntly  ftrong.  The  pain  of  his  head 
remained  as  before.  Having  a  lufiicient  number  of  ftools,  and  the  ficknefs  ftill 
continuing,  the  antimonial  powder  was  omitted.  He  was  bled,  however,  in  the 
vena  faphena,  and  his  feet  and  legs  afterwards  immerfed  in  warm  water;  during 
which,  he,  for  the  firft  time,  perfpired  copioufly.  A  biifter  was  alfo  applied  to  his 
neck. — The  fcalp  united,  with  only  a  trifling  fuppuratiofl  over  the  fractured  part 
ot  the  bone;  and  to  this  ready  union,  the  lowering  plan,  by  preventing  inflamma- 
tion, fee-ms  very  materially  to  have  contributed.  The  matter  collected  over  the 
iracture  was  difcharged  by  a  puncture,  and  the  boy  got  well.'" — Abcmethy. 


326  Of  Fractures  of  the  Scull  with  Depression. 

poral  and  frontal  hones  also  denuded  ;  part  of  one  of  the  bones 
beaten  in,  for  an  inch  in  length,  and  more  than  the  eighth  of  an 
inch  in  depth,  and  a  fracture  extending  downwards  to  the  basis 
of  the  scull, — and  yet  refrain  from  trepaning.  He  can  see  a 
fracture  similar  to  this,  with  a  part  of  the  bone  depressed  even 
a  quarter  of  an  inch  below  its  natural  level,  without  thinking  of 
making  an  effort  to  raise  it ;  and  can  even  see  the  boy  sicken  on 
the  third  day,  with  headach  and  disturbed  sleep,  with  dozing 
and  a  slight  convulsion,  without  being  moved  to  do  anv  thing 
rash  or  unbecoming.*  While  the  tyro,  just  sent  out  from  the 
schools,  makes  diligent  inquisition  into  all  the  circumstances  of 
a  fracture,  will  allow  not  even  a  capillary  fissure  to  escape  his 
jealous  search  ;  and,  where  there  is  hardly  any  visible  fissure, 
imagines  such  internal  damages  as  may  entitle  him  to  u  set  to 
work  with  his  instruments,"  and  perform  that  great  operation, 
which  is  to  be  the  pride  of  his  future  years,  "  boasting  of  that 
which  is  his  shame." 

It  is  not  honourable  to  our  profession  to  have  it  thus  proved, 
that  while  the  opinion  is  almost  universal  that  depression  of  the 
scull  must  oppress  the  brain,  the  fact  is  entirely  the  reverse : 
that  wherever  by  chance  such  depression  has  passed  unob- 
served, or  the  friends  have  refused  all  surgical  help  ;  wherever, 
by  the  deepness  and  firmness  of  the  depression,  it  has  been  im- 
possible to  raise  it ;  wherever  the  danger  of  infection  has  de- 
terred the  surgeon  from  operating,  or  he  has  resisted  the  temp- 
tation, and,  by  an  effort  of  good  sense,  has  ventured,  at  the 
risk  of  his  reputation,  to  disregard  the  established  maxim,  the 
patient  has  done  well.  This  is  enough  to  throw  a  doubt  upon 
all  that  has  been  doing  for  centuries  ;  and  makes  it  a  duty  to  tell 
you  plainly,  and  without  reserve,  that  the  desire  of  leaving,  in 
a  dangerous  operation,  nothing  undone,  is  not  wise,  and  leads 
to  nothing  but  rashness  and  violence  :  it  is  a  prejudice  so  na- 

*  A  boy,  about  twelve  years  old,  received  a  kick  from  a  horfe  in  Smithfield, 
which  ft  tinned  him  ;  and  he  was  immediately  brought  to  the  hofpital.  The  in- 
teguments of  the  forehead  were  divided  by  the  injury,  and  the  fuperciliary  ridge 
of  the  frontal  bone  depreffed  at  leait  a  quarter  of  an  inch  beloiv  its  original  level ;  the 
depreffed  portion  meafuring  about  an   inch   and  a  half  in  length. 

It  is  obvious  that  the  bone  could  not  be  thus  depreffed,  without  a  fracture  of 
fome  part  of  the  bafis  of  the  fcull  occurring  at  the  fame  time,  on  which  account 
the  cafe  might  be  confidercd  as  more  dangerous.  In  lefs  than  two  hours  he  had  reco- 
vered from  the  immediate  effect  of  thr  blo-w,  being  at  that  time  perfectly  fenfible .  Four- 
teen ounces  of  blood  were  taken  from  his  arm ;  hi<  bowels  were  emptied  by  a 
purge,  and  faline  medicines,  with  antimonials,  were  diredted  to  be  given.  He 
went  on  tolerably  well  for  two  days,  at  the  end  of  which  time,  evident  fymptoms 
of  confukrable  irritation  of  the  brain  took  place.  He  now  complained  of  pain  in 
his  hc:id ;  flept  little;  and,  when  dozing,  often  ftarted,  or  was  convulfed  in  a 
flight  degree.  To  remove  thefo  fymptoms,  he  was  bled  twice,  took  opening  medi- 
cines occaaonally,  was  kept  quiet,  and  without  light,  and  was  allowed  only  a  fpare 
diet.     By  continuing  this  plan  for  about  three  weeks,  he  perfectly  recovered. 


Of  Exceptions  to  the  general  Rule.  327 

tural  that  it  should  be  resisted  ;  it  is  a  manner  of  reasoning, 
which  is  worse  applied  to  this  operation  than  to  any  in  surgery. 
To  leave  a  Second  Stone  in  the  Bladder,  while  performing 
the  operation  of  Lithotomy,  is  to  do  nothing  :  to  leave  dis- 
eased glands  in  the  Axilla,  when  extirpating  a  cancerous  breast, 
is  to  do  worse  than  nothing  :  but  to  leave  a  slight  Depression 
of  the  scull,  even  when  the  patient  is  stunned  and  sickened, 
or  any  depression  where  there  are  no  bad  symptoms,  where  the 
integuments  are  entire,  when  the  patient  is  young,  is  to  make 
a  just  and  modest  sacrifice  of  our  wishes  and  prejudices  to  the 
safety  of  our  patient. 


SECTION    IV.. 

Exceptions  to  the  general  Rule  of  leaving  Depressioyis  to  Nature; 
or  Definitions  of  those  Cases  which  actually  require  the  use 
of  the  Trepan  and  Lever. 

I  know  not  whether  I  have  persuaded  you,  but  I  have  my- 
self, to  the  most  entire  conviction,  that  of  all  the  injuries  of 
the  scull  that  which  is  the  most  dreaded,  viz.  depression,  is  the 
least  hurtful.  I  have  seen  such  happy  recoveries,  where  the 
depression  was  left  undisturbed,  such  melancholy  scenes  when 
depression  was  raised  at  the  expense  of  large  perforations,  and 
extensive  openings  of  the  scull,  that  I  confess  myself  very  in- 
different to  this  kind  of  danger,  and  very  doubtful  of  the  pro- 
priety of  such  operations  :  the  practice  which  i.  think  so  very 
hurtful,  it  is  my  duty  to  oppose  ;  and  I  shall  now  endeavour  to 
keep  my  promise  with  you,  of  explaining,  first,  the  general 
rule,  so  as  to  give  you  confidence,  viz,  "  That  you  are  not  to 
trepan,  nor  elevate  every  depression  :  and,  next,  "  the  excep- 
tions", so  fully  as  to  prevent  you,  whiie  you  avoid  the  fault  of 
hurrv  and  impatience,  running  into  any  fatal  error  from  ne- 
glect." You  will  find  thai  I  have  considered  tbestj  exceptions 
seriously,  and  that  I  retrace  my  opinions  on  thifi  point  to  obser- 
vation and  experience. 

First,  The  general  principle  which  I  have  laid  down  is 
illustrated,  and,  I  believe,  proved,  by  this  figure,  (Fig.  1.) 
where  (a J  represents  the  point  from  which  a  fracture  of 
the  parietal  bone  is  bent  down  ;  ( b)  the  natural  level  of  the 
scull  ;  (c)  the  extent  of  the  depression,  deep  and  formidable 
when  seen  and  touched  outwardly  ;  but  the  space  betwixt  (b  & 
c)  demonstrates  how  very  little  the  depressed  bone  is  off  its 
level,  how  partial  and  trifling  the  pressure  must  be,  how  slight 
an  intrusion  this  is  upon  the  convexity  of  the  scuil  ;  and  the 


328  Of  Exceptions  to  the  general  Rule. 

truth  which  this  plan  demonstrates  as  probable,  is  proved  be- 
yond a  doubt,  since,  under  the  most  extensive  depressions  of 
the  scull,  the  patient  preserves  his  senses.  Nothing  is  more 
essential  than  that  \ou  should  have  clear  conceptions  of  the  mo- 
tives for  applving  the  trepan  :  it  is  one  great  point  gained,  to 
say  with  confidence,  that  kk  this  of  depression  is  not  among  the 
number."  I  never  saw  depression  occasion  stupor,  nor  the  ele- 
vation of  it  bring  relief ;  but  many  times  when  the  surgeons 
have  been  busy,  in  a  mob,  struggling  and  elevating  depressions, 
in  a  manner  almost  as  rude  as  that  of  O'Haloran  with  his  four 
levers,  the  boy  or  man  has  been  struggling,  remonstrating,  and 
making  every  kind  of  resistance  :*  nay,  it  is  most  singular,  and 
not  to  be  found  in  any  equal  number  of  injuries  of  the  head  of 
anv  other  complexion,  that,  in  all  the  instances  of  deep  and 
wide  depression  which  I  have  just  quoted,  or  have  yet  to 
quote,  the  patient  was  sensible. "f" 

Secondly,  Though  this  general  principle  cannot  but  be  ac- 
knowledged, it  remains  to  be  circumscribed  by  certain  definite 
rules  :  as  we  should  take  different  measures  in  a  clean  cut  of 
the  integuments,  and  a  rude  and  mangled  wound,  where  the 
parts  were  bruised,  lacerated,  and  unfit  for  adhesion,  we  must 
take  various  measures  in  fracture  of  the  scull,  according  to  its 
peculiar  circumstances  ;  and  as  there  are  circumstances  which 
are  found  to  prevtnt  the  adhesion  of  wounded  integuments  or 
wounded  scalp,  there  are  many  which  will  prevent  the  healing 

*  There  are,  in  my  recollection,  no  cafes,  and  I  find  in  my  readings  very  few. 
in  which  the  deprtffion  feems  to  have  occafioned  ftupor,  or  the  elevation  of  it  gi- 
ven relief.  The  following  obfervation  from  La  Motte,  is  perhaps  worth  your  no- 
tice as  much  as  any. 

"  A  boy"  (fays  La  Motte)  "  was  rode  over  by  a  young  prancing  horfe,  which 
pranced  upon  him.  There  was  a  great  wound,  and  much  bone  naked  ;  and  be- 
fidrs  there  was  a  confiderable  deprcflion,  apparently  made  by  the  cauker  or  heel 
of  the  fhoe.  This  boy  I  found  lying  on  his  back,  crying  out  continually  that  he 
was  falling,  that  he  was  falling  down  !  I  trepaned,  introduced  the  levator,  and 
raifed  the  deprefled  bone.  This  boy,  while  the  bone  continued  depreffed,  had 
continually  the  feeling  of  a  drunken  perfon.of  the  room  running  round  with  him: 
but  the  moment  the  bone  was  raifed,  and  the  extravafated  blood  evacuated,  he  reco- 
vered his  fenfes.''     P.  32c. 

+  A  cafe  is  related  by  Mr.  Cline,  in  his  Lectures,  of  a  feaman  on  board  au 
Englifh  fhip  in  the  Mediterranean,  being  knocked  down  by  fomething  falling 
from  aloft.  He  was  rendered  hifenlible  by  the  blow,  and  in  this  ftate  was  carried 
to  Gibraltar,  where  nothing  was  done  for  him,  and  thence  to  London,  to  St.  Tho- 
mas' Hofptal,  ftill  in  a  ftate  of  infenfibilify.  Thofe  who  were  with  him  knew 
when  he  wanted  to  eat  or  drink,  by  certain  motions  which  he  made.  He  had 
liktwife  a  catching  of  tbe  fingers  of  one  of  his  hands.  His  head  being  fhaved.  a 
dep~effion  (of  ons  of  the  parietal  bones,  I  think)  was  difcovcred,  for  which  M: . 
Cline  operated.  That  very  evening  the  motions  of  his  fingers  ceafed,  and  in  a 
few  days  his  fenfes  were  entirely  reitored.  What  is  very  remarkable,  when  he  firft 
became  rational  he  thought  himfelf  ftill  cmifingin  the  Mediterranean,  having  nc 
idea  o,  the  lapfe  of  time,  or  change  of  firuation,  which  had  taken  place.  1  do  not 
recolle<9  how  long  he  remained  in  that  hifenlible  ftate,  but  it  mud  have  been 
fcveral  months.     S. 


Of  Exceptions  to  the  general  Rule.  329 

of  a  fractured  scull,  and  cause  it  to  inflame  the  bone,  and  affect 
the  dura  mater  :  These  are  the  exceptions,  and  they  must  be 
defined,  and  I  will  now  describe  that  kind  of  depression  which  I 
judge  to  be  safe.  It  is  not  by  present  pressure  that  fracture  is 
dangerous  ;  therefore,  when  it  runs  in  a  right  line,  when  there 
is  a  general  depression,  but  no  particular  point  forced  in  upon 
the  brain  ;  where  the  declination  of  the  depressed  from  the 
sound  part  of  the  scull  is  gradual  and  uniform  ;  when  the  whole 
line  of  fracture  is  generally  depressed,  and  the  central  point  sinks 
rather  deeper  only  ;  though  you  can  feel  the  hollow  with  your  fin- 
ger, and  can  see  it  (not  without  apprehension)  when  the  coagu- 
lated blood  is  discharged  ;  yet  as  the  centre  does  not  intrude  ma- 
terially upon  the  brain,  as  this  point  does  not  dip  so  as  to  present 
points  or  spicule  to  the  dura  mater ;  as  there  is  no  rough  edge 
presented  on  the  inward  surface,  nor  any  rude  shock,  like  that  of 
a  ball,  to  deprive  the  bone  of  life,  and  prevent  its  healing  ;  as  it 
is  broken  by  such  a  force  as  fractures  other  bones,  and  is  sur- 
rounded (as  marked  at  d,  fig.  1.)  with  a  mass  of  cellular  sub- 
stance, thickened  by  inflammation,  and  by  the  injection  of  blood 
into  it,  such  as  re-unites  other  fractures,  the  scull,  pericranium, 
and  dura  mater,  all  mutually  adhere,  and  the  effects  of  such 
depression  are  never  felt. 

Upon  every  principle,  and  every  precedent,  taking  care,  how- 
ever, to  watch  the  slightest  appearance  of  fever,  rigour,  puffi- 
ness  of  the  scalp,  flabbiness,  or  gleety  discharge  from  the  wound 
we  are  bound  to  commit  such  a  case  to  nature  :  it  daily  happens 
that  boys  have  the  forehead  thus  flattened  by  the  kick  of  a  horse; 
sometimes  dangerous  spicule,  as  where  the  caulkers  of  the  shoe 
have  pierced  the  bone,  are  cut  away,  and  very  properly,  with  the 
trepan  :  sometimes,  too,  the  bone  is  elevated;  but  very  often  it 
is  left  untouched,  the  wound  lightly  stitched,  and  dressed  ,dry, 
and  the  parts  re-unite  and  heal  as  in  any  other  wound,  a  visible, 
but  harmless,  depression  remaining.  While  the  integuments 
are  entire,  the  inducement  to  leave  them  so  is  particularly 
strong  j*  when  left  entire,  the  consolidation  of  the  parts,  and 
the  absorption  of  the  blood,  is  certain,  or  almost  so  :  to  open 
it,  is  to  convert  a  simple  into  a  compound  fracture,  with  every 
danger  of  its  not  healing  favourably.  I  remember  to  have  put 
in  my  finger,  through  a  wound  in  the  scalp,  and  felt,  in  a  very 

*  If  you  follow  this  advice,  how  can  you  know  whether  or  not  there  are  any 
fpiculaj  of  bone  driven  in  upon  the  dura  mater  ?  I  have  been,  after  the  example 
of  Mr.  Birch  of  St.  Thomas'  Hofpital,  in  the  invariable  habit  of  laying  open  fuch 
tumours,  never  with  any  injury  to  the  patient  that  I  could  perceive,  and  often  with 
manifeft  advantage.  When  all  danger  of  bad  fymptoma  vanifhes,  thw  incifion  may 
be  kealed  in  a  few  days.     S. 

2T 


330  Of  Exceptions  to  the  general  Rule. 

old  woman,  near  70  years  of  age,  a  depression  of  the  parietal 
bone  of  two  inches  of  extent,  the  fracture  wide,  the  edges  rough, 
and  the  depressed  bone  apparently  driven  far  below  the  unhurt 
part  of  the  scull;  and  the  only  notes  I  have  taken  of  the  case 
are,  that  she  never  passed  one  sleepless  night,  nor  had  one  hour 
of  sickness  ;  her  appetite  never  declined  ;  that  she  sat  up  to  be 
dressed,  and  kept  her  bed  a  few  days  only,  through  precaution, 
rather  than  for  want  of  spirits  or  strength,  and  recovered  as 
from  the  most  ordinary  wound.  In  those  less  advanced  in  life 
there  is  less  danger  ;  and  we  have  the  best  authority  (the  au- 
thority of  those  whose  general  practice  is  to  use  the  trepan)  for 
affirming,  that  in  such  cases,  not  only  the  present  depression 
does  no  harm,  but  the  fracture  unites,  and  the  wound  closes  ; 
the  patient  may  even  be  seized  with  shiverings,  and  the  purt 
with  suppuration,  (strong  reason  for  suspecting  a  carious  bone) 
yet  such  abscess,  being  punctured,  will  discharge  "  a  consider- 
able quantity  of  matter,"  and  the  patient  be  in  no  danger :  najr, 
we  are  assured,  on  the  same  impartial  testimony,  that  a  bone 
loose,  and  somewhat  depressed,  will  fix  again.*  But  in  boys 
especially,  where  depressed  bone  has  in  general  no  sharp  edges  ; 
where  the  scull  rather  bends  than  breaks ;  where  the  bone  is 
vascular  and  growing,  and  the  circulation  in  it  and  in  the  inte- 
guments sound  and  vigorous,  the  chance  of  a  fracture's  healing 
is  so  great  that  I  would  not  presume  to  touch  it,  unless  in  most 
peculiar  circumstances  ;  especially  as  in  bo)s  the  dura  mater  is 
too  tender  to  serve  as  a  second  scull  to  sustain  the  pressure  of 
the  circulation  within  the  brain  :  wherever  it  is  necessary  to 
make  large  openings  in  the  cranium  of  boys,  protrusion  of  the 
brain  and  death  ensue. 

It  is  not  then  the  present,  but  the  remote  consequences  of 
depression  we  have  to  dread ;  a  depressed  fracture  is  more  apt 
to  become  carious  than  one  thac  is  direct  or  linear;  and  it  is 
as  a  fractured  Rib  or  Sternum  inflames  the  Pleura  or  Pericar- 
dium, that  depressed  fracture  of  the  scull  by  becoming  carious 
inflames  the  brain.  This  is  an  accident  which  may  happen 
in  any  form  of  fracture,  where  the  bone  is  but  laid  bare,  or 
scratched,  or  punctured,  as  well  as  where  it  is  depressed  ;  it  is 
one  for.  which  the  surgeon,  who  has  endeavoured  to  re-unite 
the  fracture,  can  be  no  more  blamed  than  he  could  be  blamed 


'  "  Samuel  Hafte  received  a  wound  on  the  upper  part  of  the  right  parietal 
hone,  of  two  inches  long,  ivitb  a  loofc  bane  and  fracture.  Though  the  ir::"ture 
could  not  admit  of  a  doubt,  yet  there  feemed  to  be  mt  little  depreffion,  and  the 
fides  of  it  were  firm  to  the  touch.  I  faw  no  reafon  for  the  operation  at  prefent, 
but  carefully  attended  to  the  fymptoms  In  the  fpace  of  four  week*  the  hone  be- 
came covered,  the  wound  healed,  and  he  has  fiuce  enjoyed  perfect  health." — 
0' Halorun. 


Of  Exceptions  to  the  general  Ride.  331 

for  an  extensive  suppuration  of  the  scalp,  where,  having  stitched 
the  lips  of  the  wound  lightly  and  nicely  together,  and  taken 
every  pains  to  prevent  suppuration,  it  had  yet  suppurated  ;  but 
it  is  an  accident  so  frequent,  and  indeed  so  much  depending  on 
peculiar  forms  of  fracture,  as  to  occasion  a  variety  of  excep- 
tions to  the  general  rule. 

llurdly,  The  first  exception  which  I  would  explain  to  you, 
is  not  of  this  nature,  but  depends  on  other  concomitant  circum- 
stances. A  fracture,  with  or  without  depression,  may  be  of 
such  extent  as  to  indicate  great  violence,  the  concomitant  symp- 
toms announcing  extravasation  :  the  fracture  traversing  the  chan- 
nel wherein  the  great  branches  of  the  arteries  oi  the  dura  mater 
are  lodged,  they  are  otten  lacerated,  and  pour  out  much  blood, 
which  may  be  actually  seen  oozing  through  the  chinks  of  the 
lracture,  and  in  such  circumstances  it  is  our  duty  to  operate  : 
but  then  our  sole  motive  for  operating  is  to  relieve  the  brain 
from  the  blood  which  oppresses  it,  not  on  account  of  the  frac- 
ture, which  only  marks  the  place  of  the  chief  violence.  Fi- 
gure 2.  may  represent  such  a  lracture  ;  where  fa)  marks  a 
wide  fracture  (through  which  the  black  blood  is  seen)  running 
down  into  the  orbit,  perhaps  into  the  basis  of  the  scull  ;  (b) 
two  other  limbs  of  this  wide  and  gaping  fracture,  running  down 
along  the  temple,  and  backwards  through  the  parietal  bone  ; 
(c)  represents  a  large  corner  of  bone  depressed,  apparently 
loose,  and  so  surrounded  and  insulated  by  the  the  various  chinks 
of  the  fissure,  that  you  would  believe,  first,  that  it  would  be 
easily  removed  if  that  were  reckoned  prudent  ;  secondlv,  that 
it  must  be  perfectly  easy  to  elevate  the  slight  depression  of  a 
bone  so  insulated;  thirdly,  you  would  be  naturally  in;  lined  to 
fear  that  such  a  bone  could  not  have  sufficient  circulation  to 
live  :  but  all  this  is  deception,  a  very  common  deception  ;  for 
such  a  bone  is  steadv,  immovable,  cannot  by  any  force  of  the 
levator  be  elevated,  and  lives,  and  granulates  :  ( dj  marks  the 
trepan  circle  which  should  be  made  in  these  circumstances,  and 
the  piece  ot  bone  being  sawed  through  and  picked  away,  the 
halt-coagulated  blood  rolls  out  as  black  as  pitch,  and  the  patient 
is  relieved,  and  finally  saved. 

This  represents  in  truth  the  head  of  a  very  stout  sailor  lad, 
who,  in  going  out  upon  the  main-yard,  to  get  in  the  studding- 
sail  boom,  fell  clear  from  the  height  of  the  main-sard  :  no  stay 
nor  tackle  broke  his  fall;  he  had  not  a  wrist,  nor  any  part  pain- 
ed or  bruised;  he  lighted  full  on  his  forehead,  which  bore  the 
whole  force  of  the  fall,  and,  by  hitting  a  cat-head,  (a  solid  pro- 
jecting clump  of  timber,  round  which  the  tackles  are  secured) 
his  scull  was  fractured  with  deep  and  wide  rents,  running  down 
towards  the  basis,  in  every  direction.     This  happened  on  Sun-. 


332  Of  Exceptions  to  the  general  Rule. 

day  evening  ;  he  was  immediately  carried  down  to  the  cabin, 
and  lay  long  insensible,  and  when  he  revived,  found  himself 
cold,  giddy,  sick  and  powerless,  and  continued  to  vomit  for 
some  hours. 

On  Monday,  when  I  saw  him,  there  was  no  delirium  nor 
confusion  of  intellect,  night  nor  day;  no  iaultering  of  the  tongue  ; 
no  dilatation  of  the  pupil  ;  no  sign  nor  degree  of  palsy  in  the 
left  side,  and  the  vomiting  had  ceased  :  he  complained  of  no- 
thing but  of  indescribable  suffering  in  his  head,  and  a  sort  of 
oppression  and  misery  during  the  night ;  yet  his  condition  was 
very  decidedly  marked  by  a  sign,  which  I  have  seldom  found 
deceive  me,  a  slowness  and  marked  intermission  of  the  pulse, 
which,  throbbing  slowly  and  heavily,  pauses  at  every  fifth  or 
sixth  beat.  The  wound  in  his  forehead  was  right-lined,  of 
small  extent,  about  an  inch  and  a  half;  not  mangled  nor  lace- 
rated ;  the  lips  not  puffed  up  by  extravasation,  but  simple,  as  it 
had  been  made  with  the  blow  of  a  poker  ;  and  through  this 
wound  the  probe,  passing  obliquely,  discovered  a  slight  depres- 
sion, a  rough  edge  of  bone,  and  wide  fractures,  through  which 
the  buttoned  point  of  the  probe  might  have  passed.  His  condi- 
tion was  singular :  he  was  a  big  and  fleshy  lad  ;  and,  from  the 
steadiness  of  his  posture,  the  sluggishness  of  his  motions,  the 
manner  in  which  his  limbs  were  folded,  and  the  slow  and  op- 
pressed way  with  which  he  spoke,  from  the  slowness  of  his 
breathing,  together  with  various  indescribable  circumstances, 
one  felt,  while  standing  over  him  and  rousing  him  to  answer 
questions,  as  if  conscious  that  he  lay  heavy  on  his  bed.*  His 
answers,  even  to  the  most  curious  questions,  were  circumstan- 
tial and  correct ;  but  they  were  extorted  by  urging  him  to  reply  : 
his  answers  to  each  question  were  delivered  slowly,  after  draw- 
ing a  long  breath,  and  with  an  oppressed  sigh.  He  seemed  to 
feel  gre^t  oppression  at  the  scrobiculus  cordis  :  his  head  always 
dropped  upon  his  breast ;  and  his  hands,  when  you  raised  them, 
dropped  heavily  bv  his  side.  You  were  conscious  of  the  pain  it 
gave  him  to  renew  a  conversation,  by  the  slowness  and  sighing 
with  which  he  began  his  replies  :  he  lay  still,  oppressed,  breath- 
ing slowly,  with  deep  inspirations,  and  he  had  a  correspond- 
ing pulse,  for  it  throbbed  slow  and  heavy,  beat  just  50  in  the 
minute,  and  at  every  filth  or  sixth  throb,  it  paused  distinctly  the 
spare  of  one  slow  pulsation. 

His  suffering  during  the  night,  he  said,  was  inexpressibly 
great,  but  it  was  such  as  he  could  in  no  shape  describe.  He  was 
told   how  doubtful  his  condition  was,  and  how  likely  that  we 

*  I  do  not  fcruple  to  copy  expreflions  of  this  inaccurate  kind  from  my  cafe- 
book,  when  I  find  them,  however  incorrect,  to  be  fuited  to  convey  thofe  lively  im- 
preffions  which  one  has  only  in  the  moment  of  looking  upon  a  patient. 


Of  Exceptions  to  the  general  Rule.  333 

ihould  advise  him  to  submit  to  an  operation.  After  passing 
one  night  more  in  this  oppressed  condition,  he  allowed  us  to 
elongate  the  incision,  making  at  the  same  time  a  crucial  one,  by 
which  these  terrible  fractures  (fig.  2.)  were  displayed  ;  but  the 
inner  surface  of  the  flaps  of  skin  was  so  exquisitely  sensible,  and 
he  was  so  far  from  feeling  all  his  misery,  that  he  insisted  upon 
being  carried  to  bed. 

But,  two  nights  more  of  that  indescribable  suffering,  which 
he  had  tried  to  express  to  us,  quite  subdued  him  :  he  said, 
"  whatever  we  pleased  to  do  with  him,  was  now  welcome." 
The  flaps  of  scalp  were  now,  on  Thursday,  in  a  state  of  suppu- 
ration ;  the  black  blood  was,  at  the  time  of  incision,  distin- 
guished through  the  fissures ;  and  upon  the  circular  piece  of 
boriH  (d)  being  cut  with  the  trepan,  rolled  out  in  large  clots.  I 
could  feel  a  great  hollow  betwixt  the  scull  and  dura  mater, 
which  was  depressed  by  the  extravasated  Mood,  and  the  probe 
passed  along  unobstructed  tor  several  inches,  in  every  direc- 
tion, from  the  trepan  hole.  To  talk  of  repeating  the  perfora- 
tions till  an  extravasation  of  this  extent  were  uncovered,  would 
be  to  think  like  a  school-boy:  the  process  was  in  this  case  sim- 
ple and  uninterrupted.  The  patient's  anxieties  and  oppression 
were  gradually  relieved.  He  was  trtpaned  on  Thursday  :  on 
Friday  he  felt  quite  relieved  ;  on  Saturday,  his  slow,  throbbing, 
and  intermitting  pulse,  had  risen  from  fifty  to  eighty  in  the  mi- 
nute ;  and  at  each  dressing  the  blood  diluted  with  a  sort  of  se- 
rous exudation  from  the  surfaces  melted  and  flowed  out.  At 
the  first  dressings,  I  made  way  lor  its  flowing  out  more  freely, 
by  introducing  the  probe,  wrapped  in  oiled  lint,  and  moving  it 
gently  round  betwixt  the  scull  and  dura  mater ;  and  as  the  du- 
ra mater  rose,  which  it  did  visibly  from  day  to  day  it  assu- 
med a  vermeil  colour  :  the  scalp,  bone,  and  dura  mater  were, 
in  course  of  a  fortnight,  one  undistinguished  mass  of  red  gra- 
nulations ;  the  process  of  healing  was  rapid  and  uninterrupted, 
not  even  interrupted  by  the  loosening  of  a  small  piece  of  bone, 
which  was  partly  cut  by  the  trepan  and  partly  insulated  by  the 
fracture,  and  which  I  picked  away,  without  the  help  of  forceps, 
with  the  probe.  I  find  that,  on  the  Sunday  following,  I  had 
been  obliged  to  turn  out  large  clots  of  blood  with  the  probe, 
which  presented  at  the  trepan  hole,  and  extended  far  under  the 
scull ;  and  that,  on  the  following  days,  I  was  occasionally  obliged 
to  use  the  syringe,  with  tepid  milk  to  wash  out  clots. 

Fourthly,  Yet  you  must  perceive,  that  it  is  not  in  such  cases, 
that  the  gaping  fracture,  or  even  the  excessive  depression,  that 
is  an  object  of  concern,  but  that  the  extrawisated  blood  is  at  once 
the  cause  of  the  d;inger  and  of  those  signs  which  denote  its  exist- 
ence ;  and  those  signs  of  extravasation  may  be  so  decisive,  es- 


334  Of  Exceptions  to  the  general  Rule. 

pecially  when  conjoined  with  fracture  and  depression,  as  to  in- 
duce you  to  cut  open  the  integuments  and  perforate  the 
scull.  This  was  proved  by  the  following  case  of  a  fine 
sailor  boy,  about  fourteen  years  of  age,  spirited,  active,  and 
very  thoughtless.  While  the  vessel  was  unloading,  he  trip- 
ped in  skipping  about  the  deck,  pitched  headlong  into  the  hold 
among  casks,  and  was  carried  up  into  the  air  in  a  state  of  stu- 
por, bleeding  from  the  nostrils  and  vomiting.  There  was  no 
external  wound,  but  a  universal  extravasation  of  blood  into  the 
cellular  substance  of  the  scalp,  especially  over  the  right  eye-brow, 
by  which  the  eye  was  almost  closed.  It  was  some  time  before 
he  was  removed  from  the  ship  in  the  roads  ;  and  when  I  first 
saw  him,  it  was  easy,  through  the  integuments,  swelled  as  they 
were,  to  distinguish  fractured  edges,  and  a  depressed  bone  ;  but 
the  extent  or  form  of  these  could  not  be  ascertained,  and  indeed 
they  never  should  have  been  with  me  a  motive  for  making  in- 
cision into  the  swelled  scalp,  but  that  he  lay  still  in  a  state  of 
stupor,  vomiting,  and  bleeding  from  the  nostrils:  his  stupor 
was  not  the  deadly  snoring  of  the  apoplectic  state  ;  it  had  the 
peculiar  character  which  I  have  just  attempted  to  delineate  :  he 
could  be  roused,  was  sensible  and  rational  when  excited,  but 
still  he  was  in  a  state  of  stupor,  into  which  he  instantly  relapsed. 
Generally  the  removing  the  patient  to  an  operation-table,  and 
almost  always  the  first  incisions,  excite  the  patient,  though  de- 
lirious, he  becomes  rational,  though  torpid,  he  is  roused;  yet 
still,  even  when  thus  roused,  his  actions  bear  the  character  of 
stupor  or  delirium.  This  boy,  when  carried  to  the  operation- 
table  was  roused  to  a  perfect  consciousness  of  every  thing 
around  him  ;  and,  when  the  operation  was  done,  said,  "I  think 
I  have  borne  it  with  spirit." 

This  boy  then  was  perhaps  a  fit  subject  for  the  experiment  of 
trying  how  far  the  powers  of  nature  might  prevail,  in  at  once 
supporting  the  system  under  oppression,  healing  wide  fractures, 
and  absorbing  much  extravasated  blood  ;  for  while  there  was 
such  extravasation  outwardly,  along  with  conspicuous  fracture 
of  the  scull,  there  was  great  probability,  almost  a  certainty,  of 
extravasation  within.  It  was  an  experiment  I  did  by  no  means 
feel  myself  entitled  to  make  ;  because  the  stupor,  the  vomiting, 
the  haejnorrhagy  from  the  nostrils  continued  :  I  therefore  made 
an  incision  into  the  tumour,  a  long  incision,  which,  directed 
by  what  I  felt  without,  uncovered  a  long  fracture.  The  lower 
part  of  the  forehead  was  more  swelled  with  suggilation ;  the 
eye  was  more  closed ;  the  edges  of  the  incision,  when  laid 
aside,  were  more  choaked  with  coagulated  blood  than  cculd 
be  well  represented  in  a  drawing:  the  coagulated  blood  was 


Of  Exceptions  to  the  general  Rule.  335 

also  injected  so  into  the  cellular  substance  about  the  pericrani- 
um, that  the  fractures  could  be  better  felt  than  seen  :  but,  one  great 
fracture  running  down  the  forehead,  passed  into  the  orbit,  and 
was  so  very  wide  that  it  easily  admitted  the  handle  of  my  scal- 
pel :  another  limb  of  the  fracture  ran  round  in  the  direction  of  the 
coronal  suture  ;  a  whole  piece  and  corner  was  deeply  depressed, 
and  so  far  locked  under  an  edge  of  the  sound  bone,  that  it  was  ne- 
cessary to  make  two  perforations,  and  to  cut  off  a  small  project- 
ing corner  with  the  finger-saw,  before  we  could  think  of  using  the 
lever.  The  blood  rolled  out  through  the  first  perforation.  The 
depression  of  the  dura  mater  by  the  blood  was  as  great  as  in 
the  former  case  ;  the  circle  in  which,  I  could  with  the  probe 
feel  it  detached,  was  as  wide  :  the  rising  of  the  pulse,  which 
had  been  oppressed ;  the  recovery  from  the  stupor ;  the  gra- 
nulation of  the  dura  mater,  and  the  closing  of  the  wound ;  and 
the  daily  issue  of  clotted  blood,  make  this,  in  all  respects,  a 
just  parallel  with  the  case  I  have  just  related.  The  extent  of 
the  wound  was  such,  that  the  boy  was  not  dismissed  till  the  9th 
of  January,  the  7th  of  September  being  the  day  of  his  fall :  but 
what  surprised  and  gratified  me  was  this, — the  piece  of  bone, 
which  had  been  depressed  and  elevated,  actually  moved  with 
each  pulse  of  the  brain,  so  loose  did  it  lie  upon  the  dura  mater. 
I  feared,  when  I  saw  the  dura  mater  through  the  trepan  holes, 
red  and  granulating  ;  when  on  the  20th  day  from  that  of  the 
operation,  I  found  also  all  the  exposed  part  of  the  scull  covered 
with  a  fine  and  florid  pile  of  granulations,  this  triangular  piece 
of  bone  excepted,  (which  continued  yellow,  quite  bare,  and 
still  moveable),  that  it  must  become  entirely  carious,  and  exfo- 
liate ;  and  that  this,  by  protracting  the  cure,  or,  by  its  exposing 
the  brain,  might  bring  the  boy  into  new  danger  :  I  had  this  im- 
pression on  the  30th  of  November,  and  marked  it  in  my  daily 
report ;  but  by  the  6th  of  December,  the  same  pile  of  florid  gra- 
nulations had  crept  along  over  the  whole  surface  of  this  portion 
of  the  scull,  and  by  the  14th  the  whole  wound  was  cicatrized. 

Such  wide  and  gaping  fractures,  then,  imply  a  very  heavy 
blow,  or  a  fall  from  a  great  height :  I  find  them  often  accom- 
panied with  deep  apopletic  stupor,  with  palsy  of  one  side,  di- 
lated pupils,  and  involuntary  stools  ;  with  groaning  and  sighing, 
an  uneasy  tossing  from  side  to  side  in  bed,  as  if  from  oppres- 
sion, and  a  frequent  raising  of  the  hand  to  the  affected  side  of 
the  head. 

Fifthly,  There  is  a  kind  of  danger  inseparable  from  certain 
forms  of  depressed  fracture,  which  no  experienced  surgeon  will 
despise.  A  flat  and  even  fracture,  having  no  particular  point 
depressed,  causing  no  stupor,  and  attended  with  no  ill  signs, 
is   by  no  means  a   fit  subject  for  operation  :  but,  where  (as 


336  Of  Exceptions  to  the  general  Rule. 

in  fig.  3.)  the  fracture  is  radiated  and  pointed,  where  the 
bones  do  not  "  lie  pashed  or  loose  upon  the  dura  mater,"  and 
yet  are  much  shivered  :  where  not  a  long  flat  edge  is  driven  un- 
der the  sound  bone,  but  particular  points  are  depressed,  pre- 
senting probably  on  their  inner  surface  spiculae  and  irregular 
and  jagged  edges,  there  is  imminent  danger,  not  from  the  de- 
pressed bone  lying  heavy  upon  the  brain,  but  Irom  its  points 
pricking  the  dura  mater,  u  hence  on  the  eighth  or  tenth  day, 
inflammation  extends  from  the  membrane  to  the  brain,  shiver- 
ings  and  tremors  come  on,  and  the  patient  dies.  Not  the  long 
and  wide  fracture  (ti  a,  fig.  3,)  nor  the  general  depression  pro- 
duced by  the  yielding  of  the  three  triangular  portions  (£,  c,  d,~) 
are  the  cause  of  clanger,  but  the  dipping  in  a  more  perpendicular 
direction  of  the  point  (7/),  which,  being  central,  has  received  a 
great  proportion  of  the  force,  and  which  by  being  driven  deeper 
than  the  lateral  parts  (6  and  c),  is  likely  to  carry  down  splinters 
from  the  inner  table  of  one  or  both  these  portions :  it  is  because 
the  scull  consists  of  two  tables,  and  not  by  the  peculiar  fragility 
(though  it  is  more  fragile)  of  the  inner  table,  that  points,  and 
spicuke  of  it  are  so  apt  to  be  driven  into  the  brain  :  when  the 
pointed  portion  (d)  is  driven  below  the  level  of  the  contiguous 
parts  (b  and  c),  it  leaves  behind  it  the  outer  table  of  each  of 
these  portions,  but  it  passes  the  inner  table,  and,  as  it  is  driven 
inwards,  every  inequality,  or  angle  cf  the  fracture,  makes  a  re- 
sistance by  which  splinters  are  not  only  carried  before  the 
point  (d),  but  driven  vertically,  like  pins  or  sharp  wedges, 
through  the  dura  mater.  The  experienced  surgeon  distinguish- 
es at  a  glance  the  forms  of  fracture  in  which  there  is  danger  of 
this  kind  :  and,  in  a  fracture  of  the  form  here  described,  radia- 
ted, pointed,  and  depressed,^  there  is  no  room  betwixt  fragments 
lapptd  over  each  other,  like  fingers  when  plaited  and  squeez- 
ed togrther,  to  admit  a  lever,  I  think  it  right  to  apply  the  tre- 
pan at  the  angle  (e)  (as  usually  there  is  such  an  angle  in  every 
fracture  of  this  species),  through  which  the  lever,  being  intro- 
duced under  the  depressed  points,  raises  them,  and  the  probe, 
being  turned  round  within  the  scull,  will  ascertain  whether  any 
rough  edges  still  present,  or  whether  any  spiculae  or  dangerous 
points  stick  in  the  membrane. 

Sixthly,  Fractures  of  this  form  may  prove  dangerous,  but 
depressions  of  the  kind  which  lam  next  to  describe  must  be  so. 
The  form  of  depression  which  happens  when  a  man  is  thrown 
Irom  a  stumbling  horse,  and  pitches  with  his  head  directly  a- 
gainst  a  stone;  or  when  he  falls  from  a  yard-arm  for  example- 
and  pitches  upon  the  deck  ;  or  when  a  block  and  tackle,  or  a 
corner-stone  from  a  building,  falls  directly  upon  his  head.  This 
fracture  is  described  by  the  ancients  under  the  title  of  Camera 


Of  Exceptions  to  the  general  Rule.  337 

Uoy  the  camerated  fracture,  as  resembling  the  inverted  tiles  of 
a  house  ;  that  centre  is  depressed  in  a  direct  line,  the  sides  de- 
cline towards  that  centre,  like  the  form  which  the  two  hands 
make  when  laid  together  edgeways.  The  form  of  this  peculiar 
fracture  has  been  but  too  minutely  described  ;  while  its  charac- 
ter has  been  less  an  object  of  attention,  though,  from  its  very 
form,  these  interences  are  plain  :  First,  that  in  consequence  of 
its  great  extent,  both  lengthways  and  from  side  to  side,  the  op- 
pression of  the  brain,  if  such  an  effect  could  be  produced  by 
depression  ol  the  scull,  should  be  most  manifest  ;  yet  I  affirm, 
from  experience,  that  such  effect  is  rarely  felt,  and  shall  prove, 
at  the  least,  that  oppression  of  the  brain  is  not  inseparable  from 
this  kind  of  depression  :  Secondly,  it  follows  that  from  the 
depth  to  which  the  central  line,  or  direct  fracture,  is  depressed, 
there  must  invariably  be  presented  two  rough  and  very  dange- 
rous edges,  which,  by  irritating  the  dura  mater,  will  cause  sup- 
puration :  Thirdly,  that  though  the  patient  should  escape  this 
danger,  the  circular  fracture  or  crack  which  surrounds  the 
whole,  and  which  must  invariably  accompany  depression  of  this 
form,  (without  which  indeed  the  bone,  in  an  adult  at  least,  could 
not  yield),  must  almost  always  insulate  the  depressed  pieces, 
they  must  in  nine  of  ten  cases  become  carious,  and  to  prevent 
these  manifest  dangers,  I  imagine  it  to  be  clearly  the  duty  of 
the  surgeon  to  elevate  and  pick  them  away,  by  pressing  in 
his  lever  betwixt  the  edges  of  fissures  usually  very  wide ;  or 
this  being  either  impracticable,  on  account  of  the  wedge-like 
impaction  of  the  depressed  portions,  or  dangerous  from  the 
dipping  of  one  end  of  so  long  and  broad  a  fracture,  while  the 
other  is  rising,  he  should  apply  the  crowns  of  the  trepan  suc- 
cessively, till  the  bone  can  be  raised  without  being  turned  in 
upon  the  brain. 

The  case  which  I  have  selected  for  illustrating  this  principle, 
is  that  of  an  old  man,  of  the  name  of  Thompson,  who  might 
have  been  saved  by  a  timely  operation,  but  who  was  lost  by  de- 
lay. He  had  fallen  headlong  down  a  precipice,  (the  Calton), 
fractured  his  scull,  had  a  double  depression  in  the  very  course 
of  the  great  longitudinal  sinus,  and  of  the  falx,  which,  if  any 
thing  could  oppress  the  brain  and  disorder  its  circulation, should 
have  produced  that  effect  :  but  so  slightly  was  he  affected,  that 
nineteen  days  elapsed  without  himself  feeling,  or  his  friends 
suggesting,  the  propriety  of  procuring  assistance.  At  the  end 
of  twenty  days,  this  was  his  condition:  the  depression  was 
manifest  to  the  touch  and  to  the  eye  ;  the  whole  extent  of  the 
bone  was  black  and  bare,  and  a  pale  granulated  fungus  surround- 
ed it :  he  had  never,  bom  the  moment  of  the  accident,  had  one 

2  U 


358  Of  Exceptions  to  the  general  Rule. 

hour  of  sickness,  or  vertigo,  or  any  considerable  pain,  but,  on 
the  twentieth,  began  to  lose  his  appetite,  became  drowsy  when 
undisturbed,  and  languid  when  forced  to  speak  or  move  ;  his 
pulse  was  rapid  and  small,  his  nights  were  passed  in  contusion. 
On  the  twenty-second  day,  he  complained  of  more  than  usual 
pain,  of  slight  vertigo,  and  of  nausea  ;  and  these  symptoms 
succeeding  a  night  of  confusion  and  delirium,  in  which  he  strug- 
gled otten  to  get  out  of  bed,  made  it  necessary  to  perform 
straightway  an  operation  so  obviously  necessary,  which  had  in- 
deed been  resolved  on,  and  delayed  only  by  necessary  arrange- 
ments. The  crown  of  the  trepan  was  applied  twice,  and  through 
each  perforation  the  lever  was  introduced,  and  the  bone  poised 
up,  but  could  not  be  safely  moved  till  the  third  perforation  set 
it  quite  free,  when  all  the  blackened  bone  was  taken  away. 

But  long  before  the  operation  was  performed,  the  fatal  in- 
flammation had  begun  ;  so  it  appeared  from  the  depth  and  ex- 
tent of  the  fatal  abscess,  which  had  indeed  destroyed  one  entire 
hemisphere  of  the  brain.  Hitherto  his  state  might  rather  be 
described  by  the  term  drowsiness  than  stupor:  but  the  delirium 
of  the  night  preceding  the  operation  was  a  decisive  and  fatal 
sign.  This  delirium  never  ceased  :  in  the  present,  as  in  all  ca- 
ses that  I  have  watched,  the  symptoms  were  aggravated  during 
the  night:  in  suppuration  of  the  brain,  every  long  slumber  is  fol- 
lowed by  a  degree  of  delirium,  and  the  fate  of  a  patient,  whose 
condition  cannot  be  suspected  from  any  symptoms  occurring 
during  the  day,  may  be  prognosticated  from  the  confusion  in 
which  he  passes  the  night.  Through  the  night  following  the 
operation,  our  patient  started  up  frequently,  struggled  to  get 
out  of  bed,  talked  incoherently,  but  the  return  of  light  restored 
his  senses,  and  during  the  day  he  was  rational  and  composed, 
but  still  he  slumbered.  This  was  his  condition  during  the  nine 
days  -that  he  survived  the  operation  :  his  pulse  was  a  hundred 
and  twelve,  weak  and  variable  ;  he  was  restless  and  confused 
during  the  day,  especially  after  slumbering,  and  was  delirious 
during  the  night  :  from  the  opening  in  the  scull,  there  was  a 
considerable  oozing  of  blood  and  of  bloody  serum.  The  third 
and  fourth  nights  after  the  operation,  were  less  perturbed  :  du- 
ring the  fifth  and  sixth,  he  was  extremely  restless  and  agitated, 
speaking  much,  and  struggling  to  get  out  of  bed:  the  dura  mater 
appeared  now  black  and  sloughing,  with  a  fetid,  thin,  and  bloody 
discharge.  On  the  seventh,  ho  became  comatose  ;  his  cheek  had 
a  circumscribed  and  hectic  flush  ;  his  pulse  beat  120,  there  was 
no  more  delirium,  he  lav  insensible,  and  passed  his  urine  and 
faeces  unconsciously  :  on  the  sixth,  seventh,  and  eighth  days,  the 
coma  became  deeper  ;  he  lay  still,  and  muttering  ;  and,  after 
slight  convulsive  rigours,  expired,  on  the  ninth  day  after  the 


Of  Exceptions  to  the  general  Rule.  339 

operation,  the  twenty-eighth  from  the  time  of  his  fall.  In  de- 
scribing deep  suppuration  ol  the  brain,  to  speak  of  the  laxavities 
and  draughts  that  are  administered,  or  of  their  effects,  were  a 
very  trivial  detail. 

Upon  dissection,  the  whole  of  the  right  hemisphere  of  the 
brain  was  found  in  a  state  of  suppuration  ;  the  basis  of  the  ab- 
scess was  very  large  ;  the  opening  through  the  dura  mater,  was 
like  that  made  by  a  large  abscess  lancet,  into  the  sac  of  any 
great  tumour :  the  medullary  substance  of  the  brain  was  soft 
and  gelatinous ;  the  part  immediateb  surrounding  the  abscess 
was  gangrenous,  marked  by  a  black  or  leaden  colour,  extend- 
ing an  inch  or  more  round  every  part  ol  the  abscess,  and  ter- 
minating in  a  disk  or  halus  of  a  deep  green  colour  :  the  left  he- 
misphere was  also,  in  a  degree,  tainted  with  the  same  colours, 
and  slightly  ulcerated  on  its  surfaces. 

Seventhly.  Punctured  fracture  is  that  form  of  wound  in  the 
bone  which  has  the  same  relation  to  these  wide  fractures  and 
broad  depressions,  that  the  stab  of  a  bayonet  has  to  the  cut  of  a 
sabre:  plainl)  and  indisputablv  requires  the  trepan,  for  in  no 
case  can  we  divine  how  deep  the  point  may  have  gone  ;  how 
far  the  ball,  weapon,  or  point,  mav  have  sunk  into  the  brain  ; 
in  what  degree  or  form  the  bone,  especially  its  inner  table,  may 
be  fractured  :  blood  is  often  extravasated,  and  often  spiculaj 
stick  in  the  dura  mater,  or  in  the  sinuses  :  the  present  injuries 
are  sufficient  motives  for  applying  the  trepan,  and  caries  is,  in 
this  form  of  fracture,  almost  inevitable.  I  hold  it  to  be  the  du- 
ty of  the  surgeon  in  all  such  fractures  to  use  the  trepan  ;  to  place 
the  centre-pin  of  his  instrument  as  close  by  the  centre  of  the 
fracture  as  its  irregularities  will  allow  ;  and  to  operate  with  a 
crown  so  large  as  to  cover  all  the  fracture,  and  cut  it  out  at 
once. 

Such  cases  remind  me  of  the  necessity  of  establishing  this  as 
a  rule  "that  all  punctured  fractures  should  be  trepaned,11  and 
of  enumerating  the  general  accidents  by  which  they  are  produ- 
ced.*      When  a  man  falls  backwards  against  the  sharp  corner 

•  The  melancholy  confequences  of  fuch  a  fracture,  are  admirably  depicted  in 
the  following  fingular  cafe,  where  the  fracture  was  fo  minute  that,  had  the  in- 
teguments been  fully  opened,  it  might  have  efcaped  inveftigation  ;  and  yet  the 
cutting  out  of  fuch  punctured  piece  of  bone  early,  could  alone  have  favedt  the  boy's 
life. 

Brand,  aged    about    14,  was  (truck   on   the  temple   by  a  pair  of  fciffors 

Hung  at  him,  the  point  of  which  ftuck  a  little  above  the  external  canthus  of  his 
eye,  till  it  was  pulled  out.  A  bit  of  fugar  tied  on  the  wound  by  his  mother  flop- 
ped the  blood.  He  complained  little  tor  two  or  three  days  ;  but  the  pain  gradual- 
ly increafed  every  day  after.  However,  he  went  ahout  till  the  eighth  day,  when 
be  fell  into  convulfions,  and  I  was  fent  for. —  There  was  a  hard  tumour  under  the 
pericranium  and  crotaphite  orafcle,  fo  tenfc,  that  a  fluctuation  in  it  could  with  dif- 
ficulty be  perceived.  The  tumour  lay  fo  exactly  under  the  artery,  that  it  could 
not  be  hid  fully  open  without  wounding  the  artery.      To  prevent  an  hemorrhage, 


340  Of  Exceptions  to  the  general  Rule. 

of  a  stove  or  grate  ;  when,  by  the  bursting  of  a  fowling-piece, 
either  the  fragmtnts  of  the  gun-barrel,  or  the  breech-pin  enter 
into  the  forehead ;  when,  by  a  blow  from  a  hammer,  from  the 
keys  of  a  crane  swinging  and  hitting  the  head ;  when,  by  the 
blow  of  a  sharp-pointed  stone,  making  a  radiated  wound  of  the 
scull,  depressed  in  the  centre  ;  when  a  splinter  lrom  a  carro- 
nade,  or  bolts,  nails,  or  other  fragments  of  iron  have,  in  a  sea 
engagement,  penetrated  the  scull ;  when  a  musket  ball,  a  dag- 
ger's point,  or  the  point  of  a  pike  or  bayonet,  sticks  in  it — the 
fractured  bone,  and  the  fragment  of  the  weapon  or  the  ball, 
must  be  cut  out  with  the  trepan,  else,  slightly  as  the  patient 
feels  the  wound,  he  will,  by  the  inflaming  of  the-  bone  and  the 
suppuration  of  the  dura  mater,  be  irrecoverably  lost,  before  the 
symptoms  indicate  danger.  These  are  almost  the  only  frac- 
tures in  which  I  think  the  largest  sized  trepan  should  be  used. 

Shocking  as  the  accident  was,  which  I  am  now  going  to  re- 
late, I  hardly  ever  saw  a  punctured  fracture  that  I  would  so  wil- 
lingly have  left  to  nature  as  that  which  happened  to  Biilv  Came- 
ron, a  boy  of  about  twelve  years  of  age.  He  was  occupied  a 
whole  morning  with  his  little  play-fellows,  in  swinging  upon  ana- 
rea  door  :  the  staple  was  loose :  the  insecurity  of  the  door  made  a 
part  of  the  pleasure  they  had  in  swinging  upon  it.  When  it  came 
round  to  this  little  boy's  turn,  the  stone  in  which  the  staple  was 
socketed,  gave  way  ;  the  gate  of  cast  iron,  the  corner-stone,  and 
the  boy,  tumbled  all  at  once  into  the  area  ;  a  good  woman  ran 
out  instantly  to  lift  the  boy,  and  found  him  lying  with  his  head 
pinned  to  the  ground,  betwixt  two  iron  spikes,  one  of  which 
had  grazed  and  wounded  the  left  side  of  the  head,  while  ano- 
ther had  pierced  the  sculi,  and  was  sticking  in  the  parietal  bone, 
the  weight  of  the  gate  and  the  stone  lying  above  him.  She 
carried  him  in  her  arms  into  fur  house,  where  he  lay  without  a 
sigh  or  a  struggle,  cold,  pale,  and  d.ath-like,  for  ten  minutes  : 
he  then  began   to  draw  long  breaths,  to  groan,  and  to  open  his 

therefore,  I  cut  the  artery  and  all  through  to  the  bone  with  a  biftoury.  About 
half  announce  of  well- conditioned  pus  ruihed  out,  by  which  he  was  greatly  relie- 
ved— When  I  thought  enough  of  blood  had  bten  dilcharged,  it  was  eafily  flopped 
by  a  dry  doflil  and  a  haltpenny  in  the  comprefs — Next  day  he  was  brought  to 
town  ;  and  Dr.  Gikhrifl  ordered  fuch  internal  medicines  as  were  judged  proper  for 
him,  and  he  continued  eaficr  for  two  or  three  days.  After  which  the  violent  hcad- 
ach  and  vomiting  returned  and  laited  two  or  three  days  more,  when  a  large 
quantity  ol  matter  burft  out  from  within  the  fcull,  which  again  gave  fome 
cafe. — But,  though  the  orifice  in  the  integument  was  enlarged,  no  further  dif- 
charge  could  be  procured.  He  died  in  a  day  or  two  after,  being  the  fixteenth 
day  after  the  accident. — On  opening  his  head,  half  a  pound  of  pus  was  found 
in  the  brain,  and  the  hole  in  the  fcull  made  by  the  fcifiors  would  not  admit 
the  point  of  a  pin His  friends  abfolutely  refufed  the  trepan,  by  which  he  pro- 
bably might  have  been  faved.  His  death,  however,  was  of  ufe  to  other*,  who 
more  readily  iubmitted  to  the  operation,  upon  feting  the  fatal  conlequences  of 
neglecting  it  in  his  cale. 


Uf  Exceptions  to  the  general  Rule.  341 

eyes  ;  when  his  elder  brother  passing,  and  hearing  of  the  nature 
of  the  accident,  went  into  the  house  licrn  a  common  impulse  of 
humanity,  and  iound  his  little  brothtr  in  this  mangled  condi- 
tion. He  called  a  s^dan  chair,  and  placing  h.m  on  his  knee  on 
pillows,  brought  him  to  the  Infirmary. 

B\  the  time  his  lather  and  mother  had  arrived,  he  was  quite 
collected,  and  in  his  senses,  he    was  sitting   up,  while  his  head 
was  shaved,  his  mother   took    him  upon  her  knee  and  soothed 
him  ;   he  laid  down  his    head    upon  her  bos'  m,  and  cried  :  but 
he  wiped  away  the  blood  carefully  and  nieek  with  his  handker- 
chief;  was  perfectly  collected  and  obedient,  and  neither  cried 
nor   struggled.       The   wounds  were,  one   upon  the  left  side, 
slight  and  superficial,  trom  the    grazing  of  one  of  the  spikes; 
another  in  the  right  temple,  or  rather  about   the    centre    of  the 
parietal  bone,  very  deep.     The  punctured  wound  of  the  integu- 
ments admitted  a  probe,  which,   passing  obliquely  backwards, 
encountered  the  edge  of  a  deep   depressed   fracture:  the  iron 
point  had  not  directly  pierced  the  scull,  but  crushed  and   burst 
through  the  bone  obliquely,  and,  by  a  lateral  pressure,  it  had  so 
bent  clown  a  piece  ol  the  scull,  that  the  fracture  was  long  and  the 
depression  broad;  but  the  integuments  were  only  slightly  wound- 
ed, they  were  punctured,    and  not  torn.       The  boy   was  in  his 
perfect  senses,  without  even  that  tremor  or  agitation  which  such 
an  accident  might  occasion  ;  no  weakness  of  one  side  ;  no  stu- 
por ;  no  vomiting  ;  no  dilatation  of  the  pupil  ;  no  slowness  nor 
pausing  of  the  pulse,  such  as  usually  accompanies    t  {fusion  of 
blood.      I  was  averse  trom  the  proposal  of  opening  the  integu- 
ments, and  ventured  to  prognosticate  the  worst  consequences  if 
a  fracture,  already  so  extensive,  was   trepaned,   and  the  bones 
torn  away  :   but  the  boy,  though  there    v.  as  not  the  shadow  of 
an    ill   symptom,  was  trepaned  ;  a  long   incision  was  made  : 
two  piects  ot  bone,  each  half  an  inch  broad    and   an   inch  long, 
were  twisted  and  pulled  away  ;  two  smaller  fragments  were  loo- 
sened and  pulled  away  by    the  help  ol   the  levator  and  forceps: 
all,  in  short,  that  was  depressed,  was  disengaged  and  separated  ; 
and  the  bo) ,  whose  condition  was   after  the  accident  doubtful, 
lay  now  in  a  most  perilous  state  :  The  integuments  cut  up  to  the 
extent  of  three  inches;  the   scull  opened   to   the  same  extent  ; 
the  dura  mater  left  to  sustain  alone  the  force  of  the  arterial  pul- 
sations, and  the  brain  alread\  protruding,  even   while  the  dura 
mater  was  still  entire.      I  never,  in  boys,  find  the  dura  materca- 
pable  of  supporting  itself ;  wherever  the  openings  are  thus  wide, 
it  inflames,  sloughs,  gives  way  at  one  or  more  points,  and  the 

PROPER    SUBSTANCE    OF    THE     BRAIN,    previously     suppurated, 

md  ready  to  form  a  lungus,  protrudes  :  so  it  was  in  this  case. 
**  Upon  examination,    after   death,  it  was  found    that  the 


342  Of  Exceptions  to  the  general  Rule. 

chief  disorder  lay  in  the  right  hemisphere  of  the  brain,  though 
it  was  in  part  communicated  to  the  left.     The   left  ventricle 
was  somewhat  enlarged,  its  surface  irregular  and  soft,  with 
suppuration,    while    a  dirty    greenish-coloured  pus  lined  the 
walls  :  the  inflammation,  thus  communicated  to  the  left  side, 
was  universally  diffused  :  the  substance  of  the  brain,  in  its  an- 
terior part,  remained  natural ;  the  cortical  and  medullary  parts 
were  distinguished  by  the  usual  colours  and  forms,  but  the  sub- 
stance of  the  brain,  where  it  approaches  either  inflamed  sur- 
face, viz.  that  of  the  ventricle,  or  of  the  hemisphere,  assumes 
a  dirty  olive  green  colour,  which  muddy  and  dusky  green  is 
the  prevailing  colour  of  the  inflamed  or  half-gangrened  parts. 
Immediately  opposite  to  the  wide  opening  of  the  scull,  all  dis- 
tinction of  the  medullary  and  cineritious  substance   ceases;  the 
brain  has  degenerated  into  a  confused  mass,  which  may  be  re- 
presented, in  a  drawing  or  a  model,  by  a  ground  of  olive  green 
touched  with  spots  of  vermilion,  like  extravasattd  blood.     The 
dura  mater  covering  the  right  hemisphere  of  the  brain,  was 
much    thickened,  and  leathery-like  ;    its   vessels  conspicuous, 
red,  and  turgid,  and  coated  with  a  tenacious  coat  of  pus,  great- 
ly resembling,  and  in  some  degree   partaking  of  the  nature  of 
coagulable  1\  mph ;    but  there  was  much  unequivocal  pus  spread 
over  all  the  hemisphere,  reaching  even  to  the  basis  of  the  scull. 
The  dura  mater    was  perforated,  but   not   round  the  margin 
of  the  circle  made  by  the  trepan,  as  if  wounded  by  the  teeth  of 
the  instrument;  the  openings  were  round  and  centrical  in  re- 
gard to  the  naked  part  of  the  membrane,  and  were  filled  by  the 
protruding  parts  of  a  fungus.  The  most  difficult  and  interesting- 
part  of  the  anatomical  inquiry  was  that  which  related  to  the  state 
and  origin  of  this  fungus :  it  proceeded  apparently   from  the 
membranes  of  the  brain,  from  the  pia  mater  ;  it  was  elongated 
from  the  surface  of  the  brain  in  the  form  of  threads,  the  remains, 
I  presume,  of  vessels  which  gave  consistence  and  strength  to 
what  in  other  respects  resembled  mucus." 

Eighthly.  One  principle,  relating  occasionally  to  every  form 
of  fracture;  to  the  depressed  ;  the  angular  and  fractured  wound 
of  the  scull ;  the  mere  rimaor  fissure  ;  nay,  even  to  the  slight- 
est bruise  of  a  bone,  is  this — that  every  such  fracture  may  be- 
come carious.  When,  by  carelessness  or  design,  a  fracture 
has  been  quite  neglected,  or  imprudently  treated  ;  when,  along 
with  a  fracture  or  fissure,  the  scull  has  been  grinded  and  brui- 
sed by  a  carriage-wheel,  or  grazed  and  deadened  by  a  musket- 
ball  ;  when  the  wound  and  the  exposed  bone  has  been  much  ne- 
glected or  much  tormented,  by  the  ignorant  surgeon,  the  frac- 
tured part  becomes  carious ;  when  the  wound  becomes  pale  and 
flabby,  the  bone  still  seeming  to  the  touch  of  the  probe  bare  and 


Of  Concussion  and  Compression  of  the  Brain.  343 

rough,  or  in  part  exposed,  yellow,  duskish,  or  inclined  to  black- 
ness ;  when  the  patient  sickens  and  becomes  languid,  with  a 
furred  tongue,  a  hot  skin,  and  a  febrile  pulse,  and  a  chorded 
feeling  within  the  head — let  the  surgeon  no  longer  show  hishu- 
m  mity  or  skill,  by  watching  his  patient,  but  make  haste  to  per- 
forate the  scull ;  if  he  perlorate  early,  he  will  find  but  a  little 
cream-coloured  pus  upon  the  dura  mattr,  which  will  granulate 
and  re-unite  with  the  inner  surface  of  the  scull  ;  but  if  he  wait 
but  three  days,  the  ulceration  will  affect  the  brain. 

Let  this,  qualified  with  such  exceptions  as  your  own  good 
sense  and  experience  may  suggest,  be  your  rule  of  practice.  It 
is  not  by  neglecting  depression,  which  never  is  in  itself  hurtful, 
but  bv  disregarding  a  carious  bone,  and  the  slight  but  mortal 
signs  of  internal  suppuration,  that  many  patients  are  lost. 


DISCOURSE  XIX. 


ON  THE  STATES  OF  CONCUSSION  AND  COM- 
PRESSION OF  THE  BRAIN  ;  WITH  EXAMPLES 
NARRATIVE  AND  DESCRIPTIVE. 


SECTION    I. 


Preliminary  Observations. 

J.  O  treat  fractures,  wounds,  and  other  open  and  manifest 
injuries  ol  the  scull,  prudently  and  skilfully,  may  be  thought 
difficult  ;  but  how  to  reason  concerning  those  internal  injuries 
which  are  hidden  from  the  senses,  and  marked  only  by  variable 
and  uncertain  signs,  must  ever  be  perplexing.  Perhaps  there 
is  nothing  more  generally  desired  uy  the  pvoression  than  some 
decisive  marks,  denoting  the  particular  nature  oi  that  stupor  in 
which  a  patient  lies  oppressed  after  a  fall  or  a  heavy  obtuse 
blow.  But  there  is  no  such  sign  ;  we  are  doomed  to  proceed  in 
our  profession  always  with  a  degree  of  uncertainty,  and  to  re- 


344  Of  Concussion  of  the  Brain. 

gulate  our  conduct  by  a  perpetual  and  attentive  exercise  of  our 
judgment  and  senses.  It  is  only  by  a  deliberate  and  calm  re- 
view of  the  circumstances  attending  concussion,  that  we  can 
arrive  at  any  thing  like  a  conclusion. 

To  reason  upon  the  cause  of  every  phenomenon  in  the  liv- 
ing body,  is  natural  and  unavoidable,  and  does  by  no  nuans 
contribute  either  to  multipl)  or  confirm  whatever  prejudices  we 
may  have  :  it  is  only  from  refusing  to  reason  that  our  worst  pre- 
judices have  arisen  :  and  prejudices  of  ignorance  are  infinitely 
more  dangerous  than  the  prejudices  ol  those  who,  being  willing 
to  reason,  are  of  course  open  to  conviction,  and  inclined  to  en- 
ter into  the  discussion  of  whatever  new  views  or  unobserved 
phenomena  are  brought  to  light.  Nothing  perhaps  can  be  more 
unmeaning  than  the  word  Concussion,  which  is  not,  in  the  com- 
mon acceptation,  accompanied  with  any  conviction  ot  the 
structure  of  the  brain  being  disordered  by  the  shock,  the  term 
implies  a  belief  that  the  affection  is  ot  the  nature  usually  deno- 
minated Nervous  !  that  it  is  inscrutable  in  its  nature  !  that,  as 
we  know  nothing  of  the  immediate  cause,  we  can  do  nothing  to 
recover  our  patient!  that  whatever  phenomena  we  observe,  are 
such  as  are  usually  designated  signs  of  debility  ;  and  from  this 
persuasion,  and  an  indistinct  and  confused  analogy,  (as  Mr. 
Abernethy  observes)  betwixt  fainting  and  concussion,  stimulants 
and  rvine,  the  most  dangerous  of  all  medicines,  are  poured 
down. 

If  concussion  be  indeed  this  inscrutable  nervous  affection,  un- 
attended with  physical  disorder,  we  must  become  mere  specta- 
tors ;  there  is  an  end  of  reasoning,  and  in  such  uncertainty  it 
were  better  to  refrain  from  practice.  But,  the  comparing  the 
brain  with  other  parts  and  organs  of  the  body,  will  bring  to  our 
recollection  many  consolatory  circumstances,  which  will  encou- 
rage you  to  believe,  that  here  also  our  profession  may  be  useful. 
What  does  a  bruise,  a  shock,  and  a  general  injury,  do  to  a 
limb?  Does  it  produce  any  sort  of  disorder  in  a  limb,  which 
it  may  not  produce  in  the  more  delicate  substance  of  the  brain? 
When  a  man  is  hurt  by  the  oblique  blow  of  a  cannon-ball,  or  has 
his  thigh  bruised  by  riding  furiously  against  a  carriage,  by  a 
fall,  or  by  a  log  of  wood,  a  block  of  stone,  or  any  heavy  body 
falling  upon  him,  what  does  he  feel  ?  nothing  but  numbness  : 
the  part  is  torpid  ;  he  hardly  knows  how  much  he  is  hurt ;  he  is 
lame  ;  and  we  can  hardly  believe  that  any  internal  or  physical 
disorder  has  taken  place  so  suddenly !  yet  before  he  is  reco- 
vered from  his  confusion,  or  is  able  to  mount  his  horse,  the 
limb  is  stiff  and  swelled;  the  swelling  increases  every  moment; 
the  suffusion  of  blood,  under  the  transparent  skin,  shows,  by 
the  speedy  discolouring  of  the  part,  that  the  swelling,  (too  sud- 


Of  Concussion  and  Compression  of  the  Brain.  345 

den  to  proceed  from  increased  vascular  action)  proceeds  truly 
from  blood  extravasated  by  the  ruptured  vessels,  and  there  is 
no  reason  to  doubt  that  the  swelling  in  the  deeper  parts  is  from 
the  same  cause  :  the  vessels  or  the  limb  have  g.ven  way  in  many 
parts  ;  its  cellular  substance  is  choaked  with  blood  :  if  the  suf- 
fusion be  so  universal  and  so  great  as  to  suffocate  the  arterial 
action,  the  limb  never  recovers,  all  living  action  stops,  it  gan- 
grenes and  dies  :  if  the  blood  be  injected  in  such  a  degree  as  to 
create  only  pain  and  disorder,  the  arterial  action  is  rather  excit- 
ed, and  heat,  pain,  redness,  and  suppurative  inflammation,  take 
place  :  if  the  blood  be  less  generally  injected  into  the  limb,  it  is 
more  easily  absorbed,  and  the  swelling  is  rtsolvtd  without  red- 
ness or  pain.  Of  this  suite  of  phenomena  I  must  needs  remind 
you,  before  proceeding,  to  observe  in  what  degree  these  ap- 
pearances take  place  in  shocks  or  blows  upon  the  head,  and  in 
what  degree  they  are  likely  to  affect  the  lunctions  of  the  brain. 


SF.CTION    II. 

Of  Concussion. 

The  patient  who  has  fallen  from  a  great  height,  and  lies  in- 
sensible from  the  shock,  has  sustained  the  principal  injury  in 
that  system  of  vessels  which,  from  all  that  1  have  related  to 
you,  is  the  most  delicate,  and  the  most  susceptible  of  extra- 
vasation. Nor  is  there  any  mark  wanting  ot  extravasation, 
slighter  or  greater,  general  or  local,  having  taken  place  in  the 
brain  :  nervous  affection  (if  we  are  still  to  use  this  unmeaning 
term)  might,  for  a  moment,  confound  the  functions  of  the  brain, 
as  a  man  is  not  only  stunned,  but  sickened  by  a  blow  of  the  fist; 
but  the  patient,  who  has  suffered  a  concussion,  lies  insensible, 
snoring,  and  with  his  senses  oppressed,  and  is  in  a  state  resem- 
bling that  of  apoplexy  or  intoxication  ;  his  forehead  is  swelled, 
his  eyes  often  closed,  and  his  features  deformed  with  extrava- 
sated blood  ;  blood  gushes  at  once  trom  his  nostrils,  mouth,  and 
eyes  ;  his  pulse  is  slow  and  pausing  ;  his  limbs  and  joints  loose 
and  relaxed  ;  the  pupils  of  his  eves  dilated  ;  his  breathing  slow  ; 
his  whole  body  cold  ;  you  hardly  know  that  he  is  alive,  but  by 
his  groans.  If  blood  has  thus  burst  from  every  part  of  this 
system  of  vessels,  is  it  likely  that  the  brain  has  escaped  ?  If 
the  blood-vessels  of  the  nostrils,  of  the  throat,  of  the  ears,  have 
burst  from  the  shock,  and  blood  is  also  effused  under  the  skin, 
is  it  likely  that  the  delicate  substance  of  the  brain  should  es- 
cape the  same  degree  of  suffusion  ?  It  is  indeed  true  that,  when 
the  patient  dies,   and  his  brain  is   dissected  in  that  coarse  and 

2X 


346  Of  Concussion  and  Compression  of  the  Brain. 

slovenly  manner,  which  it  but  too  common,  and  by  boys  who 
hardly  know  its  natural  colour  and  forms,  it  stems  as  if  nothing 
had  happened  to  account  for  the  sudden  death  of  the  patient ; 
and  it  is  confidently  reported  so,  because  there  is  no  fracture  of 
the  scull,  nor  anv  conspicuous  effusion  of  blood :  but  when  a 
brain  thus  deranged  is  dissected  bv  a  master  who,  by  judging 
what  is  likely  to  happen,  knows  what  to  look  for  ;  the  pheno- 
mena, though  little  perceptible  to  an  ignorant  man,  must  be  in- 
teresting to  a  thinking  observer. 

"A  man"  (says  Mr.  Abernethy)  M  having  fallen  from  the 
roof  of  a  brew-house,  a  height  of  at  least  eighty  feet,  had  his 
fall  broken  by  touching  the  ground  first  with  his  wrist,  which 
was  dislocated  and  mangled  ;  his  forehead  next  struck  the 
ground,  and  his  face  was  bruised,  but  his  cranium  was  unin- 
jured :  he  lay  at  first  almost  inanimate,  cold,  and  with  a  feeble 
pulse :  when  he  became  warm,  he  had  stertorous  breathing,  a 
dilated  pupil,  and  a  profuse  perspiration  ;  his  pulse  rose  to  140, 
he  recovered  a  degree  of  sensibility,  his  pupil  contracted,  and 
his  eve-brows  were  drawn  into  a  frown;  but  his  pulse  again  sub- 
sided ;  the  animal  functions  gradually  failed  ;  he  died  the  fol- 
lowing day  ;"  and  his  head  was  dissected  by  Mr.  Abernethy, 
who  reports  the  state  of  the  brain  in  these  words  :  "  On  dissec- 
tion, there  appeared  every  mark  denoting  violent  inflammation 
of  the  brain  and  pia  mater,  of  short  duration.  The  minute  ar- 
teries of  the  pia  mater  were  turgid  with  blood  :  in  many  places 

THERE  WAS     THE  APPEARANCE     CALLED    BLOOD-SHOT,    which 

was  also  to  be  seen  in  the  lining  of  the  ventricles.  Dark-co- 
loured, and  in  some  places  bloody  coagulable  lymph,  filled  all 
the  recesses  between  the  tunica  arachnoidea  and  pia  mater. 
On  dividing  the  substance  ot  the  brain,  all  its  vessels  ap- 
peared AS  IF  INJECTED  WITH  BLOOD.'1* 

Every  word  of  this  report,  (more  impartial  than  any  I  could 
relate  on  my  own  authority,)  conveys  the  idea  of  turgescence 
of  vessels,  and  general  cellular  effusion,  throughout  the  whole 
substance  of  the  brain,  and  makes  good  the  parallel  betwixt  that 
state  designated  -by  the  term  Concussion  of  the  Brain,  and  the 
benumbed  and  torpid  condition  of  a  limb  whose  arteries  are 
burst  and  cellular  substance  suffused  by  a  blow  :  it  is  not  possi- 
ble to  imagine  circumstances  more  suited  to  support  the  paral- 
lel than  that  suite  of  phenomena  which  takes  place  in  concussion. 
The  patient  who  has  fallen  from  a  great  height,  or  otherwise 
suffered  tha£  shock  which  so  deeply  affects  the  functions  of  the 
brain,  is  found,  when  lifted  from  the  ground,  cold,  pale,  mo- 

*  There  is  a  preparation  in  the  mufeum  of  St.  Thomas'  Hospital  of  a  train  with 
a  laceration  in  one  of  its  hemispheres  from  a  fall,  which  the  lubject,  from  whom 
it  was  taken,  received.     S. 


Of  Concussion  and  Compression  of  the  Brhin.  347 

tionless  without  pulse,  without  sense,  and  is  as  in  a  fainting 
fit ;  if  he  continues  cold,  and  passes  his  urine  and  faeces  invo- 
luntarily, he  dies.  The  first  signs  of  returning  life  are  deep 
and  oppressed  groans,  the  cold  sweat  breaking  on  his  temples, 
and  a  fluttering  motion  in  the  pulses  :  when  laid  in  bed,  when 
warmed  and  restored  to  lite,  the  groans  become  more  frequent, 
he  seems  deeply  oppressed,  he  tosses  his  limbs  from  time  to 
time  ;  his  face  is  flushed,  his  nostrils  dilated,  his  breathing  la- 
borious and  noisy,  his  pulse  slow  and  heavy,  and  has  all  the 
symptoms  of  deep  apoplexy  :  by  the  second  day  his  pulse  has 
risen  to  120;  his  lips  are  parched,  his  skin  dry,  his  eye  more 
open  ;  he  stares  widely,  but  is  insensible  ;  and  being  roused,  he, 
after  a  short  and  confused  struggle,  and  muttering,  as  in  low 
delirium,  falls  down  again  into  a  heavy  slumber,  from  which, 
if  bled  and  purged  profusely,  and  his  head  bathed  with  cold  vi- 
negar, the  surgeon  having  the  good  sense  to  refrain  from  giv- 
ing opium  or  wine,  he  gradually  recovers.  It  would  appear, 
from  this  series  of  symptoms,  that  whatever  general  effusion 
takes  place  in  the  moment  of  the  shock,  is  slowly  absorbed  ;  and 
that  the  febrile  inflammatory  action,  which  such  a  state  of  the 
sensorium  excites,  in  the  days  immediately  succeeding  the  fall, 
is  harmless:  yet  not  unfrequently  there  is  a  true  Typhomania; 
the  pulse  rises  higher,  and  throbs  powerfully ;  and  the  patient, 
after  long  tossing  and  oppression,  starts  from  his  bed,  strikes 
and  struggles  with  his  attendants,  and  subsides  again  into  a 
state  of  torpor  ;  but  by  profuse  evacuations,  and  bold  prescrip- 
tions, escapes  the  danger  of  an  inflamed  brain,  though  the  ac- 
tion sometimes  terminates  in  continued  insanity,  followed  by 
imbecilitv. 

These  successive  states,  first  of  coldness  and  stillness  in  all 
the  vital  actions,  with  oppressed  brain,  and  next  of  high  arterial 
action,  accompanied  with  delirium,  have  alvvavs  struck  me,  as 
intimating  strongly  the  parallel  (so  natural  in  every  other  point 
ot  view)  betwixt  a  contusion  of  a  limb,  or  of  any  other  organ  of 
the  body,  and  concussion  of  the  brain :  nor  am  I  over  anxious, 
when  I  find  my  patient  quite  insensible,  lying  in  a  state  of  stu- 
por, resembling  intoxication,  if  that  first  stupor  be  followed  by 
arterial  action  and  the  signs  of  inflammation,  for  then  I  know 
the  oppression  is  from  no  local  cause  :  nor  am  I  alarmed  when 
he  becomes  delirious,  for  that  is  a  state  little  more  than  febrile, 
which  I  have  usually  observed  to  be  a  sure  forerunner  cl  reco- 
very ;  there  is  in  such  case  nothing  essentially  to  oppress  the 
vital  functions,  or  to  caus<j  death. 


•  (     348     ) 

SECTION    III. 

Of  Compression. 

When,  in  place  of  general  suffusion  and  disordered  circu- 
lation, some  greater  vessel  has  given  way,  and  either  under 
the  dura  mater,  or  in  the  substance  of  the  brain,  there  is  a  par- 
ticular effusion  of  blood,  the  scene  is  very  different  from  that 
now  described  :  the  patient,  oppressed  by  an  effusion  of  blood, 
is  never  insensible,  (unless  he  is  about  to  expire)  and  rarely  de- 
lirious ;  his  pulse  never  rises,  but  is  slow,  heavy,  and  pausing 
at  every  filth  stroke;  his  pupil  is  sometimes  dilated  ;  one  side 
usually  paralysed,  or  at  least  still  and  motionless,  while  the 
other  often  shakes  with  a  sort  of  tremulous  convulsion,  which 
returns  at  regular  intervals,  and  is  attended  with  a  quivering 
and  irregular  pulse,  cold  extremities,  and  insensible  evacua- 
tions, when  he  is  about  to  expire. 

Extravasation  more  frequently  arises  from  a  blow  or  fall  up- 
on a  hard  body,  and  is  more  connected  with  fracture  of  the 
scull  than  concussion,  which  arises  rather  from  a  shock  than  a 
blow  :  extravasation  is  more  of  the  nature  of  a  local  injury  :  the 
patient,  when  raised  up,  is  cold,  pale,  and  motionless,  but  to  this 
no  usual  heat  ensues ;  he  tosses  as  under  some  oppressive  feel- 
ing, and  often  lifts  his  hand  towards  the  injured  side  of  the 
head  ;  he  lies  with  his  eyes  shut,  groans  as  from  oppression, 
but  is  always  sensible  ;  stares  at  you  when  roused  ;  answers 
whatever  questions  you  ask  rationally,  but  in  monosyllables  ;  he 
seems  impatient  when  teazed  with  questions  ;  his  answers  are 
pronounced  with  a  sigh  or  a  groan  ;  he  is  correct  in  answering 
to  the  circumstances  of  his  fall,  even  to  the  nature  of  the  op- 
pression he  suffers,  and  to  the  part  of  his  head  that  is  pained, 
towards  which  he  moves  his  hand,  though  irregularly,  when- 
ever he  is  desired  :  in  his  tossing  he  sometimts  rises  upon  his 
elbow ;  when  requested  to  rise,  he  sits  up,  and  takes  the  drink 
which  he  calls  for,  but  soon  sinks  clown  again  into  a  slumber, 
more  like  sleep  than  apoplexv,  and  tosses  and  groans  more  as  his 
sleep  becomes  deeper  :  the  oppression  and  tossing  are  insepara- 
ble from  this  condition  of  the  sensorium,  and  the  pulse  is  slow, 
pausing,  beatingno  more  thanfiity  in  a  minute,  and  interrupted 
at  every  fifth  or  sixth  stroke,  especially  while  the  patient  is  ly- 
ing in  deeper  slumber,  or  when  in  particular  danger.  I  believe 
I  have  rartly  seen  a  patient,  to  whom  an  operation  or  any  kind  of 
assistance  could  be  useful,  quite  insensible  from  mere  oppres- 
sion of  extravasated  blood  ;  and  of  this  I  am  very  sure,  that  I 
have  innumerable   times  seen  the  patient   whose  extravasation 


Of  Compression.  349 

was  so  great  as  to  prove  fatal,  such  as  was  found  upon  dissec- 
tion to  cover  one  entire  hemisphere  of  the  brain,  retain  his  per- 
fect senses,  and  recollect  minutely  the  circumstances  of  his  fall, 
with  a  consciousness  all  along  ol  every  thing  that  was  said  or 
done  about  him. 

I  have  just  described  a  condition  which,  I  would  fain  flatter 
myself,  can  hardly  be  mistaken,  which  at  least  is  not  likely  to 
be  confounded  with  the  total  stupor  of  concussion.  In  the 
first  degree  of  extravasation,  the  person  lying  oppress- 
ed with  extravasated  blood,  is  not  insensible,  but  tosses  and 
groans  from  oppression,  replies  when  spoken  to,  feels  giddv, 
and,  when  able  to  express  his  feelings,  says  that  every  thing 
seems  to  turn  round  ;  he  pukes  from  time  to  time,  and  has  a 
slow,  heavy,  and  pausing  pulse  :  it  you  add  to  these  signs,  that, 
in  his  tossing,  you  perceive  that  one  leg  or  arm  still  moves, 
while  the  opposite  arm  and  leg  lie  almost  still  and  motionless, 
you  will  seldom  be  deceived  ;  and  finding  these  symptoms  to 
continue  lor  days,  the  oppression  to  become  deeper,  the  vomit- 
ing to  cease,  and  the  pulse  to  decline  in  strength,  becoming 
slower  as  it  becomes  feeble,  it  is  vour  duty  to  apply  the  trepan, 
and  often  vou  are  successful.  These  are  the  signs  of  slighter 
extravasation,  which  yet,  without  the  assistance  of  the  surgeon, 
becomes  desperate  :  for,  in  a  few  days,  the  side  opposite  to  that 
which  received  the  blow  becomes  manifestly  paralytic  ;  and  as 
the  extravasation  and  oppression  of  the  sensoriuin  increase, 
the  palsy  is  followed  by  convulsion  ;  while  the  one  side  becomes 
paralytic,  the  other  is  seized  with  slight  tremors,  and  soon 
after  the  pulse  becomes  weaker,  though  it  can  hardly  become 
slower,  the  natural  heat  declines,  the  patient  expires  :  wherever 
such   convulsion  accompanies  the  palsy,  it  is  too  late  to  operate. 

In  tiie  si  cond  degree  of  extravasation,  when  the  pa- 
tient is  paralytic,  or  completely  oppressed,  from  the  hist  mo- 
ment, and  there  is  no  perceptible  interval  betwixt  the  paralysis 
of  one  side  and  declining  of  the  vital  powers  ;  when  he  lies  op- 
pressed and  moaning,  raises  his  hand  frequently  towards  his 
head,  but  is  not  deeply  insensible,  nor  has  the  pupil  much  di- 
lated ;  if  he  speaks,  when  teazed,  though  slowly  and  difficultly, 
and  then  in  a  particular  manner  raises  his  hand  to  his  head,  the 
evidence  of  extravasation  is  complete,  the  patient  is  in  the  ut- 
most danger,  the  operation  should  immediately  be  had  recourse 
to,  and  perforating  with  a  large  trepan,  and  giving  vent  to  the 
coagulated  blood,  which  rolls  out  thick  and  black,  sometimes 
relieves  the  palsy,  restores  the  senses,  and  finally  saves  the  pa- 
tient's life. 

But  there  is  a  third  degree  of  extravasation,  invari- 
ably fatal ;  and  I  believe  the  symptoms  I  am  now  to  describe 


350  Of  Compression. 

indicate  in  general,  that  extravasation  which  either  expands  it- 
self over  the  lower  parts  of  the  brain,  or  extends  from  the  up- 
per parts  to  the  basis  of  the  scull,  raising  the  nerves  from  their 
origins,  and  distending  them  betwixt  the  basis  of  the  brain  and 
the  foramina  through  which  they  pass  out.  The  condition  I 
have  here  to  describe  is  that  of  total  insensibility  and  grinning 
convulsion  ;  an  insensibility  unaccompanied  by  stertor  or  snor- 
ing, but,  on  the  contrary,  with  a  pale  face,  cold  extremities, 
and  a  fluttering  pulse  ;  a  convulsion  agitating  not  one  side,  but 
chiefly  affecting  the  features  of  the  face,  jerking  the  head  back, 
and  stiffening  the  neck  :  the  convulsion  resembles  that  of  the 
locked  jaw  ;  and  it  is  very  distracting  to  look  upon  such  a  pa- 
tient, for  the  symptom  brings  an  absolute  conviction  to  the 
mind  of  the  spectator  that  the  disorder  is  fatal. 

The  patient's  condition  may  be  thus  characterised  ;  he  is  taken 
up  cold,  insensible,  with  a  dilated  pupil,  and  hardly  any  signs 
of  life,  and  recovers  heat  very  slowly  and  imperfectly  :  after 
lying  oppressed,  groaning,  deadly  pale,  with  a  dilated  pupil, 
the  extremities  cold,  and  the  eye-Jid  remaining  raised  as  you 
open  it,  unless  you  lay  it  down  again,  he  begins  on  the  second 
day  to  be  affected  with  convulsive  twitches  ;  the  cheek  is  par- 
ticularly distorted,  the  whole  body  is  still  and  cold  ;  the  con- 
vulsion increases  in  violence,  and  returns  with  a  degree  of  re- 
gularity every  ten  minutes  or  quarter  of  an  hour:  at  each  return 
of  the  convulsion  he  continues,  while  you  can  count  two  hun- 
dred or  more,  to  have  the  cheek  and  corner  of  the  mouth  raised, 
the  eye-brow  and  all  the  features  of  that  side  violently  distort- 
ed, with  spasmodic  twitches,  the  neck  rigid,  the  head  jerked 
violently  round  and  bent  backwards  upon  the  neck,  with  inter- 
rupted strokes  ;  and  each  convulsive  twitch  is  accompanied  with 
a  catch  of  the  respiration,  a  distortion  of  the  mouth,  and  with 
a  noise  of  hick  I  luck  !  repeated  at  each  twitch,  while  the  con- 
vulsion lasts.  It  seldom  continues  long :  on  the  third  or  fourth 
day  the  convulsions  grow  weaker  ;  the  extremities  and  the 
whole  body  become  cold  ;  the  pulse,  which  is  not  at  all  to  be 
felt  during  the  convulsion,  trembles  during  the  intervals,  and 
the  patient  expires. 

These  two  statts  of  concussion  and  compression  bear  a 
strong  analogy  with  the  relative  states  of  apoplexy  and  pal- 
sy. Concussion,  there  is  every  reason  to  believe,  is  not  a  mere 
nervous  affection,  else  it  could  not  be  permanent,  but  a  suffu- 
sion into  the  substance  of  the  braiD,  resembling  the  ecchymosis 
or  bloodv  suffusion  of  a  bruised  limb,  attended  with  symptoms 
resembling  apoplexy,  and  terminating  usually  in  a  gradual  ab- 
sorption and  slow  recovery  ;  sometimes  in  high  inflammatory 
action  and  sudden  delirium,  in  Typhomania,  or  rather  that  al- 


Of  Compression.  351 

ternation  of  Delirium  and  Coma,  which  is  almost  inseparable 
from  such  a  state  of  the  sensorium  :  while  compression,  pro- 
ceeding from  extravasation  of  blood  is  plainly  palsy;  begin- 
ning in  stupor,  without  insensibility,  and  ending  in  Hemiplegia 
and  convulsions  ;  but,  with  this  special  distinction,  that  Palsy, 
proceeding  from  rupture  of  vessels  overcharged  by  the  apoplec- 
tic arterial  action,  is  a  disease  of  the  brain  itself,  is  attended 
with  destruction  of  the  cerebel  substance  and  is  thence  incu- 
rable ;  while  the  paralytic  state,  proceeding  Irom  a  shock  or 
blow,  consists  in  extravasation,  foreign  to  the  substance  of  the 
brain,  external  even  to  the  dura  mater  ;  is  merely  a  local  com- 
pression, not  directly  injurious  to  the  cerebel  substance,  and 
thence  is  curable  :  the  moment  the  extravasation  is  let  out,  the 
patient  raises  his  eyes,  knows  his  friends,  and  moves  the  af- 
fected side.  The  truth  or  probability  of  these  parallels  will 
best  appear  from  narratives  of  such  accidents  as  you  are  likely 
to  meet  with  in  practice. 

Being  called  to  Hamilton,  to  visit  a  gentleman,  an  officer  in 
the  7th  Dragoons,  who  was  supposed  to  have  a  fracture  of  the 
scull ;  I  found  that  in  riding  a  wild  horse  in  a  court-yard  of 
the  barracks,  unaccustomed  to  the  heavy  bit  of  the  cavalry  equi- 
page, he  had  checked  his  horse  in  rearing,  and  pulled  him  back, 
and  the  horse  falling  upon  him,  he  was  knocked  down  and 
struck  to  the  ground  with  great  violence,  his  occiput  encoun- 
tering the  hard  beaten  gravel :  he  lay  pale,  pulseless,  and  insen- 
sible, was  restored  to  heat  very  slowly,  and  continued  in  a  pro- 
found stupor,  snoring  and  motionless.  I  arrived  the  following 
day,  and  found  him  still  insensible  ;  his  pupil  not  dilated,  his 
tongue  furred,  his  hand  hot  and  dry  ;  his  pulse  high,  his  face 
flushed  ;  his  looks,  when  roused,  wild  and  distracted  ;  he  in- 
stantly, after  being  disturbed,  fell  down  again  into  a  state  of 
stupor,  and  nothing  could  rouse  him  to  any  recollection  of  his 
situation,  nor  enable  him  to  articulate  even  a  monosyllable. 
Upon  consulting  with  Mr.  Taylor,  the  regimental  surgeon, 
formerly  of  Mercer's  Hospital,  a  man  of  the  best  education, 
and  of  strong  good  sense,  we  agreed,  however  unpromising  his 
condition  might  appear  to  his  friends,  to  report  to  Colonel  Heul, 
that  he  was  in  no  danger;  that  we  should  make  no  incisions  ; 
that,  by  profuse  evacuations,  this  fever  might  be  prevented 
from  rising  to  delirium  ;  that,  after  slumbering  a  few  days,  he 
would  gradually  recover  his  senses.  Presuming,  from  this  in- 
fallible mark  of  quick  pulse  accompanying  the  stupor,  that  the 
stupor  was  void  of  danger,  I  left  him  with  confidence  ;  and,  by- 
letters  from  Mr.  Taylor,  had  the  comfort  to  learn  that,  after 
slighter  dawnings  of  sense  and  reason,  he  was,  bv  bleeding  and 
strong  purges  of  calomel  and  jalap,  perfectly  restored,  before 
the  week  had  elapsed. 


352  Of  Compression. 

Concussion,  in  a  greater  or  less  degree,  is  almost  insepara- 
ble lrom  that  kind  ol  shock  to  which  the  head  is  exposed  when 
a  man  is  thrown  from  on  horseback  ;  sometimes  it  is  accompa- 
nied with  fracture  or  extravasation,  and  thence  questions  of 
great  delicacy  and  difficult)  often  arise.  The  first  head  I  ever 
dissected,  after  an  accident  ot  this  nature,  was  that  of  a  young 
gentleman,  who  having  rode  on  a  pleasure-party  to  Roslin,  ex- 
ceeded in  wine,  was  ill  able  to  manage  his  horse,  was  thrown, 
and  died  on  the  fourth  day  :  but  in  his  scull  was  found  not  the 
slightest  trace  of  fracture,  nor  within,  the  slightest  extravasa- 
tion ;  nor  could  any  peculiar  appearances  be  remarked  in  ex- 
amining the  substance  of  the  brain  itself,  except  general  red- 
ness of  the  pia  mater,  vessels  extremely  turgid,  and  many 
bloody  points.  Whence  we  perceive  how  narrowly  those  es- 
cape who  have  violent  concussion  ;  they  invariably  die,  if  the 
pulse  continues  low,  or  is  at  any  time  intermitting. 

Another  young  gentleman,  on  his  return  from  a  like  excur- 
sion, was  thrown  from  his  horse,  lay  in  a  death-like  stupor  for 
ten  days,  during  which  period  the  blood,  which  had  at  first 
gushed  from  his  nose,  mouth,  and  ears,  continued  to  flow  un- 
remittingly from  his  right  ear.  The  shock,  which  thus  bursts 
the  vessels  on  these  delicate  surfaces,  cannot  but  have  a  like  ef- 
fect on  the  delicate  cerebel  substance  within  :  the  senses  and 
intellect  suffer  from  this  suffused  state  of  the  brain,  but  the  hse- 
morrhagv  from  these  vessels  probably  saves  the  internal  part  of 
the  system  from  any  extreme  violence  ;  at  all  events,  it  is  cer- 
tainly observed,  that  such  issue  of  blood  from  the  mouth  and 
nostrils,  though  a  sign  of  great  violence,  is  favourable  to  the 
patient's  recovery  ;  and  if  any  such  haemorrhagy  is  dangerous, 
it  is  that  from  the  ear,  for  there  is  little  doubt  that  it  must  come 
from  those  internal  vessels  which  traverse  the  ear  :  yet  this 
young  gentleman  entirely  recovered. 

In  such  cases,  wine  and  the  heat  of  exercise,  youth,  and 
health  and  strength,  prepare  the  vascular  system  but  too  well 
to  assume  an  inflammatory  action,  and  to  re-act  powerfully  ; 
thence  it  often  happens  that,  in  place  of  lying  like  these  young 
men,  torpid  and  oppressed,  the  patient  bursts  out  of  bed,  strug- 
gles with  the  attendants  with  maniacal  strength,  and  is  very 
difficultly  subdued,  and  in  great  danger  ot  ultimate  violence  to 
the  structure  of  the  brain  from  sut-h  high  and  continued  vas- 
cular action.  This  I  saw  conspicuously  exemplified,  in  a  young 
man,  uncommonly  athletic,  accustomed  to  violent  exercises, 
who,  being  thrown  from  his  horse  when  riding  extremely  hard, 
not  brutally  intoxicated,  but  furious  with  wine,  lay  for  five  days 
in  a  state  of  profound  stupor,  from  which  he,  after  staring, 
struggling,   and   muttering,  wakened  to  such  a   phrenzy  that 


Of  Compression,  353 

four  stout  men  with  difficulty  held  him  down  in  bed,  and  yet  he 
recovered,  and  reformed,  and  now  lives  in  perfect  health. 

These  familiar  examples,  such  as  you  will  daily  meet  with 
in  practice,  cannot  perhaps  be  more  happily  closed  than  with  a 
short  case  from  Jacotius;  it  stands  recorded  in  his  commentary 
on  the  third  aphorism  of  the  first  book  of  Hippocrates.  w  We 
have  observed''  (says  this  author)  M  ol  those  who  have  the  brain 
injured,  some  dying  suddenly,  others  lying  oppressed  and  snor- 
ing, while  others  have  blood  issuing  from  the  nose,  ears,  and 
mouth,  and  yet  live:  one  patient  of  mine  having  lain  speech- 
less a  long  while,  and  apparently  dying  in  convulsions,  started 
suddenly  from  his  bed,  in  the  middle  of  the  night,  fell  upon  the 
attendants  with  maniacal  fury,  and  feUed  every  mother's  son  of 
them  to  the  ground,  except  a  Franciscan  monk,  a  lusty  able  fel- 
low, against  whom  he  maintained  a  long  battle,  with  feet,  and 
hands,  and  talons :  the  monk  called  loudly  for  help  to  those 
who  were  already  felled,  but  in  vain  ;  they  lay  strewed  on  the 
ground,  while  he  struggled  alone  with  the  iurious  patient,  who 
seized  alternately  clubs,  fire-irons,  piss-pots,  whatever  he  could 
lay  hands  on  ;  and  laying  hold  at  last  of  an  iron  stanchel,he  tore 
it  from  the  window  with  incredible  strength :  he  had  now  near- 
ly levelled  the  monk  with  his  fellow- watchers,  and  would  have 
beaten  out  his  brains  with  a  stone  of  forty  pounds  weight,  which 
he  lifted  and  aimed  to  throw  at  his  head,  when  the  monk,  breath- 
less and  exhausted,  but  desperate,  collected  all  bis  strength  into 
one  last  effort,  and  gave  him  a  kick  on  the  cods,  which  brought 
him  to  the  ground.  This  man,  savs  Jacotius,  I  entirely  cu- 
red." This  example  of  horrible  phrenetic  delirium,  I  quote  in 
proof  of  what  I  have  constantly  remarked,  that  delirium  is  the 
least  unfavourable  symptom  and  the  most  curable. 

The  more  fatal  accident  of  extravasation  is  attended  with 
symptoms  less  terrible,  and  with  a  comparatively  slight  affec- 
tion of  the  intellect  and  senses :  I  have  been  confounded  often 
to  see  the  patient  recollected  and  sensible,  under  a  compression 
so  decisive  as  to  cause  paralysis  of  one  side  :  somnolency,  not 
stupor,  is  truly  the  mark  of  this  state. 

John  Hutchison,  a  sailor  lad,  of  twenty  years  of  age,  fell 
down  stairs,  and  lay  in  a  state  singularly  characteristic  of  com- 
pression of  the  brain  :  his  condition  was  described  to  me  by  a 
good  woman,  who  was  very  careful  of  him  from  the  moment 
of  his  fall,  for  he  was  the  companion  of  her  son,  who  had  fol- 
lowed him  to  sea  ;  when  the  one  bov  was  gone  abroad,  the  o- 
ther  would  not  stay  at  home.  This  lad,  on  a  visit  to  his  father, 
perfectly  sober,  going  negligently  up  an  outside  stair,  fell,  but 
whether  three  steps,  as  a  workman  reports,  or  the  whole  flight, 
as  this  woman's  husband  believes,  we  could   never  certainly 

2  Y 


354  Of  Compression. 

learn  :  this  good  woman,  who  lived  in  the  house  under  his  fa- 
ther, was  abroad  at  the  time,  but  her  husband  heard  the  fall,  so 
violent  was  the  shock,  and  running  out,  carried  him  up  stairs 
with  the  assistance  of  a  mason  who  was  working  in  the  close. 
When  she  came  home,  she  went  up  to  him,  and  found  him  ly- 
ing oppressed,  as  in  a  deep  sleep  ;  she  asked  him  often  what 
happened,  and  how  he  was,  which  he  answered  always  in  two 
or  three  words,  passionately  and  impatiently  pronounced,  4t  that 
he  was  better,"  M  that  he  would  soon  be  well,"  "  that  he  would 
lie  and  sleep  a  little,"  still  he  begged  that  they  might  let  him  lie 
still  and  sleep.  His  tongue  sometimes  faltered  ;  he  answered  best 
when  most  roused  ;  there  was  a  cold  sweat  all  over  him  %  his 
face  was  exceedingly  pale,  he  yawned  perpetually,  and  always 
when  offered  drink,  &c.  cried,  "let  me  lie  and  sleep  :''  he  vo- 
mited frequently  during  the  two  first  hours  after  the  fall :  his 
left  side,  his  left  arm  at  least,  was  plainly  powerless,  he  never 
moved  it  in  concert  with  the  right :  he  lay  in  a  slumbering  con- 
dition, groaning  and  tossing  as  if  oppressed  ;  mutttring,  but  al- 
ways conscious  of  his  condition  ;  complaining  of  his  head,  and 
able  to  answer :  when  this  good  woman  sat  him  up  in  bed,  or 
when  he  raised  himself  to  pass  his  urine,  he  complained  often 
of  his  breast,  and  sometimes  of  his  bell)',  but  continually  of  his 
head  :  while  quiet  he  had  no  snoring,  and  slept  like  a  child,  till 
after  being  bled  by  the  surgeon  of  his  ship,  irom  which  time  he 
enjoyed  no  more  of  that  placid  sleep.  On  the  third  day,  this 
woman  brought  him  up  a  basin  of  warm  milk,  and  he  seemed 
to  like  it;  she  raised  him  in  bed,  he  sat  up  and  took  the  basin 
in  his  own  hand,  and  when  she  gave  it  him,  saying,  take  it  my 
good  lad,  he  answered,  "  1  will,  I  will,  but  do  not  trust  to  my 
hand  only  ;"  yet,  with  her  help,  he  held  it  to  his  head,  and 
drank  it  off.  He  complained  continually  of  his  head  ;  and  in 
whatever  way  roused  or  disturbed,  he  begged  they  would  let 
him  sleep  ;  "  if  they  would  let  him  sleep  a  little  longer,  he  said 
he  would  go  down  to  Leith  and  go  on  board." 

This  good  woman  went  up  to  see  him  at  seven  in  the  morn- 
ing of  the  fourth  day  ;  she  found  him  still  slumbering,  and  con- 
tinually complaining  of  his  head  ;  sudden!)  he  was  seized  with 
a  strong  convulsion,  raised  himself  a  little  in  bed,  and  thumped 
incessantly  with  his  hand  upon  the  side  of  the  bed,  sinking  with 
the  paralytic  arm  as  well  as  with  the  sound,  and  all  the  while  he 
kicked  and  struggled  with  his  feet;  at  last  his  leit  hand  was  sud- 
denly seized  with  a  violent  spasm,  the  wrist  was  strongly  bent 
down  towards  the  fore-arm,  the  fingers  stood  out  rigid  at  right 
angles  with  the  hand,  and  from  that  moment  he  never  moved 
that  arm  more,  his  hand  continuing  rigid  in  this  distorted  form. 
But  the  convulsion  did  not  then  cease  ;  it  continued  from  seven 


Of  Compression.  355 

in  the  morning  till  eight :  notwithstanding  these  terrible  con- 
vulsions, and  this  spasmodic  palsy  of  the  left  hand,  he  retained 
his  sense's,  spoke  sensibly  when  roused,  supported  himself  in 
some  degree  in  b*  d,  complained  sometimes  of  his  belly  and  of  his 
head;  and  when  asked  about  the  state  of  his  bowels  from  the 
time  of  h.s  (all.,  answered  collectedly  and  correctly.  This  was 
on  Thursday,  the  fourth  day  from  the  fall :  on  Friday  morning, 
I  saw  him,  for  the  first  time  ;  and  in  the  evening  by  six  o'clock 
he  was  dead. 

"  In  the  last  da}'  of  his  existence,  he  still  retained  his  senses  ; 
he  lay  in  a  perpetual  slumber,  but  had  no  puking  ;  his  tossing 
and  anxieties  were  very  distressing  to  see  ;  his  face  was  deadly 
pale,  his  right  eye  stood  immovable  when  opened,  the  pupil 
Ixing  widely  dilated  ;  while  his  left  (though  his  left  side  was 
paralysed)  remained  irritable  and  moveable,  the  pupil  of  it  was 
contracted,  and  it  turned  quickly  from  the  light  ;  his  pulse  was 
small,  quick,  and  fluttering,  like  that  of  a  sick  child  ;  and  the 
vital  motions  so  affected,  that  it  appeared  manifestly  that  they 
could  not  go  on  ;  his  extremities  were  cold,  and  I  judged  him 
d\  ing  :  but  nothing  surprised  me  more  than  to  find,  upon  lilting 
his  eye-lid,  that  I  could  rouse  him  to  speak  ;  when  I  bade  him 
put  out  his  tongue,  he  did  so,  and  when  I  spake  loud  and  im- 
pressively, and  asked  where  his  pain  was,  he  raised  his  right 
hand,  though  in  an  irregular  way,  and  laid  it  upon  his  head." 

u  This  very  stout  young  man  expired  about  six  o'clock  on 
Friday  evening;  and  the  following  evening  we  found,  upon  dis- 
secting his  head,  no  tumour,  nor  even  a  bloodv  effusion  in  the 
integuments,  but  in  the  cranium  a  large  and  wide  fracture,  tra- 
versing the  parietal  bone,  and  running  through  its  whole  length  : 
unconnected  with  that,  on  the  vertex,  was  a  small  fissure,  pe- 
netrating only  through  the  first  table  :  under  the  centre  of  the 
parietal  bone  lav  a  very  large  coagulum  of  blood  ;  it  was  as 
large  as  the  whole  hand,  bating  the  points  of  the  fore  and  mid- 
fingers,  and  thicker  than  the  fleshy  part  of  the  palm  ;  it  was  ve- 
ry firmly  congealed,  and  came  off  in  one  cake  like  the  placenta 
of  a  foetus,  leaving  a  very  deep  depression  in  the  brain,  into 
which  you  might  have  laid  the  back  of  your  hand." 

It  is  not  mv  intention  to  accumulate  authorities  for  what  I 
know  to  be  a  plain  fact,  but  will  go  on  to  represent  to  you  the 
condition  of  the  patient  while  labouring  under  symptoms  un- 
doubtedly mortal. 

u  A  very  old  man  was  carried  into  the  hospital,  who,  after  a 
fall,  lay  insensible  and  convulsed  :  no  relations  accompanied  him 
to  tell  what  had  happened  :  two  sons,  who  afterwards  came, 
were  at  once  brutal  and  perverse,  seemingly  indifferent  to  his 
sufferings,  and  yet  sternly  and  impudently  refusing  to  allow  us 


356  Of  Compression. 

to  proceed  in  the  way  that  prudence  and  the  necessities  of  the 
cas^  required.  He  was  a  very  old  man,  with  bald  temples,  a 
naked  scalp,  and  not  the  slightest  appearance  ot  injury  on  the 
head:  he  lay  in  a  deep  stupor,  immovable,  except  when  agi- 
tated with  a  convulsion,  which  returned  every  ten  minutes, and 
became  more  frequent  as  his  strength  declined;  his  eyes,  which 
Were  closed  during  the  interval  ot  stupor,  opened  when  the  con- 
vulsion approached,  and  stood  staring  wide,  with  a  much  di- 
lated pupil  :  first  the  cheek  and  features  on  the  right  side  of  the 
face  were  drawn  up  into  a  ludicrous  grin  ;  then  the  neck  stiffen- 
ed, the  head  was  jerked  backwards,  and  the  jaws  worked  back- 
wards and  forwards  with  a  violent  spasm  ;  the  tongue  and  throat 
Were  also  affected,  and  the  lips  made  that  kind  ot  noise  that 
follows  when  we  draw  the  breath  through  the  closed  teeth,  to 
prevent  the  saliva  escaping  by  the  angle  ot  the  mouth  :  alter 
continuing  two  minutes  or  more,  the  convulsion  terminated, 
with  deep  groans,  in  a  state  of  stupor.  His  unnatural  sons 
would  not  suffer  us  to  touch  one  hair  of  his  head  ;  and  on  the 
evening  of  the  second  day,  when  he  died,  they  came  with  a 
mob  of  vagabonds  at  their  heels,  and  carried  away  the  bodv, 
with  a  degree  of  precipitation  which  inclined  us  to  believe  that 
there  was  something  particular  in  the  manner  of  this  blow  which 
they  were  afraid  dissection  might  reveal." 

Not  a  moment  should  be  lost  when  such  symptoms  appear  : 
the  extravasation  mav  be  in  the  ventricles,  on  the  basis,  or  with- 
in the  substance  of  the  brain  ;  and  if  so,  the  man  is  gone  be- 
yond redemption  ;  but  if  it  be  only  on  the  surface,  and  there  is 
a  possibility  of  saving  his  life,  it  can  be  only  by  immediate  ope- 
ration :  when  the  symptoms  of  extravasation  are  accompanied 
with  fracture  running  downwards  towards  the  basis  of  the  scull, 
we  mav  despair  of  doing  good.* 

"  A  big  and  strong  man,  a  common  labourer,  fell  down  three 
steps  of  a  stair  ;  but  there  is  every  reason  to  believe  he  had 
struck  his  head  on  the  edge  of  a  bucket,  hitting  that  part  where 
a  projecting  iron  hinge  joins  the  iron  handle  with  the  tub  : 
when  raised  up,  he  was  pale,  cold,  and  pulseless  ;  cordials  were 
given  him,  he  was  restored  to  heat,  and  then  blood  was  observ- 
ed to  distil  from  his  nostrils  and  right  ear.  Being  carried  into 
his  own  house,  he  passed  a  disturbed  and  restless  night,  till  to- 
wards morning'that  he  enjoyed  a  calm  sleep.  He  lay  still  and 
motionless  the  second  day  ;  his  eyes  seemed  dead  and  glazed, 

*  Whenever  there  is  a  fracture  at  the  anterior  and  inferior  angle  of  the  parietal 
bone,  accompanied  with  fymptoms  of  compreffion,  nothing  but  an  immediate 
operation  can  probably  fave  the  life  of  the  patient ;  becaulc  fhould  the  princi- 
pal meningeal  artery  be  torn,  as  it  frequently  is  under  fucii  circumflances,  it 
pours  out  its  blood  with  fuch  force  as  to  prove  very  quickly  fatal :  of  this  I  have 
lately  feen  three  inftances.     S. 


Of  Compression.  357 

the  pupils  of  both  were  dilated,  contracting  only  with  the  very 
strongest  light  ;  his  jaws  seemed  clenched,  his  teeth  closely 
shut,  his  lips  retracted  and  turned  backwards,  uncovering  the 
teeth  as  in  grinning  ;  he  breathed  slow  and  heavily  through  his 
nostrils  ;  he  was  paralytic  of  his  left  side,  had  involuntary 
Stool?,  and  passed  his  urine  in  the  bed. 

M  Yet,  upon  being  stirred  and  roused,  he  looked  up  wild 
and  bewildered,  and  had  trequt  ntly,  during  the  night,  attempt- 
ed to  get  out  of  bed  ;  his  pulse  was  weak  and  fluttering,  and 
his  bod)  cold  ;  he  was  not  so  insensible  but  that  a  purge  ope- 
ratt  d  briskly,  though  then  and  always  his  stool?  passed  uncon- 
sciousb  :  his  face  was  pale  and  shrunk  ;  he  lav  but  a  few  mi- 
nutes in  one  posture  ;  he  thtn  turned  and  struggled,  and  a  sort 
of  loam  issued  from  betwixt  his  closed  tee  th,  while  his  lips 
were  retracted  into  a  grin  ;  his  cheek  was  distorted,  and  his 
jaws  worked  perpetually,  so  that  you  heard  his  teeth  grinding. 
He  was  permitted  to  lie  too  long  in  this  desperate  state  unassist- 
ed. When  mv  brother  and  1  saw  him  together  on  the  third 
day,  the  paleness  of  the  face  and  coldness  of  the  body  had  in- 
creased, the  stools  were  involuntary,  the  pulse  extremelv  fee- 
ble, almost  imperceptible;  we  called  immediately  a  consultation, 
rather  to  witness  what  was  to  be  done,  than  to  give  advice  in  a 
case  so  plainlv  desperate  :  perceiving,  though  there  was  not  the 
slightest  swelling,  a  degree  of  livor  on  the  temple,  my  brother 
made  an  incision,  and,  turning  down  a  large  angular  flap  of  scalp 
and  temporal  muscle,  uncovered  the  temporal  bone  down  to  the 
zygoma,  and  in  doing  so  felt  his  knite  grate  against  a  rough 
and  widt  fracture  ;  the  flesh  of  the  muscle  being  cleared  away, 
a  very  rude  fracture  was  seen  to  run  horizontally  through  the 
parietal  and  temporal  bones,  its  branches  passed  down  under 
the  zygoma  to  the  basis  of  the  scull,  blood  oozed  through  the 
chinks  of  it,  and  a  large  trepan  being  applied  directly  above  the 
zygoma,  very  black  grumous  blood  rolled  out.  He  died  in 
about  fourteen  hours." 

Your  own  good  sense  will  suggest  to  you  that,  besides  those 
decisive  conditions  of  the  intellect  and  bodilv  functions  which  I 
have  endeavoured  to  characterize,  there  must  be  man)  interme- 
diate states,  extremelv  perplexing  and  difficult  to  resolve  into 
anv  simple  principle  ;  in  all  things  I  wish  to  leave  you  to  your 
own  discretion  ;  in  many,  I  am  sorry  to  say,  you  can  have  no 
precise  rules  from  anv  teacher,  but  must  trust  to  your  own  pe- 
netration and  judgment  :  experience,  or,  in  other  words,  the 
habit  of  reasoning,  so  as  to  infer  from  external  signs  the  kind 
and  degree  of  internal  injury,  will  enable  you  to  resolve  the  most 
anomalous  svmptoms  ;  but  that  condition  of  the  brain  in  which 
general  suffusion  of  blood  is  lollowed  by  inflammation,  delirium, 


358  Of  Compression. 

and  death,  that  condition  which  is  marked  by  convulsions  and 
spasms  resembling  those  of  Hydrocephalus,  and  with  a  pulse 
indicating  nothing  of  oppression,  is  of  all  the  anomalous  states 
of  the  organ  the  most  frequent.  I  cannot  remember  that  I  was 
ever  more  perplexed  how  to  act  than  in  the  following  case. 

"  A  poor  boy,  of  thirteen  years  of  age,  in  scrambling  with 
his  play-fellows,  on  a  Sunday  afternoon,  about  the  ruins  of  a 
house  which  workmen  were  pulling  down,  fell  from  one  of  the 
windows,  a  height  of  fourteen  feet,  and  struck  his   forehead 
against  a  beam.     There  appeared  upon  the  forehead,  close  to 
the  root  of  the  nose,  a  soft  elastic  tumour,  and  a  general  suggil- 
lation  of  blood,  which  entirely  closed  the  eyes;  he  was  stunned, 
and  lay  in  a  death-like  stupor  for  a  quarter  of  an  hour,  but  en- 
tirely recovered  :  he  had  been  universally  bruised,  for  he  vo- 
mited blood,  which  also  flowed  in  a  full  stream  from  his  nose  ; 
his  pupil  was  contracted  ;  his  pulse  regular  and  strong,  beating 
90  in  a  minute.     Next  day  the  vomiting  continued  ;  his  pulse 
was  still  full  and  strong  :  upon  being  bled,  the  vomiting  ceased, 
and  the  pulse  subsided  both   in  strength  and  frequency  :  the 
night  he  passed  tolerably,  though  restless,  feverish,  and  in  pain ; 
he  often  carried  his  hand  to  his  forehead,  complained  of  the 
pain,  and  sometimes  talked  wildly  through  his  sleep.     The  se- 
cond night  he  passed  in  great  confusion,  with  much  delirium, 
and  when  most  rational  he  complained  grievously  of  his  head, 
while  a  thin  and  bloody  serum  distilled  from  his  right  ear,  with 
great  pain  behind  the  ear,  where  it  would  appear  he  had  sus- 
tained a  degree  of  injury,  which  might  well  happen  in  a  fall  so 
irregular  among  stones  and  beams.     On  the  third  day,  the  tu- 
mour of  the  forehead  subsided,  and  the  eye-lids  opened  :  on 
pressing  the  tumid  part  of  the  forehead,  he  complained  of  intol- 
erable pain  ;  his  pulse  continued  high  and  rapid  ;  the  bleeding, 
purges,  leeches,  and  other  sedatives,  were  renewed ;  his  sleep 
during  the  night  of  the  third  was  more  composed  and  natural, 
and  he  had  no  unfavourable  change,  till  ten  o'clock  in  the  morn- 
ing of  the  fourth  day  ;  when  he  became  very  hot,  feverish,  and 
restless  ;  vomited  much ;  the  vomiting  was  excited  by  repeat- 
ing the  cathartic,  and  even  by  taking  the  acidulated  drinks  which 
were  ordered  him  ;  at  four  in  the  afternoon  he  was  seized  with 
extraordinary  contortions,  and  strong  spasms  of  the  abdominal 
muscles,  with  violent  tremors  of  the  whole  body,  and  grinding 
of  the  teeth  :  his  breathing  was  affected  by  the  violence  of  the 
spasms  in  the  abdominal  muscles  ;  it  was  noisy  and  laborious, 
but  not  slow  nor  oppressed,  and  the  pulse  beat  1 20  in  the  mi- 
nute :  towards  afternoon  all  parts  of  the  body  were  at  times 
convulsed  ;  he  howled  as  if  distracted  with  pain  of  the  head, 
and  his  eyes  squinted  horribly ;  he  grinded  his  teeth  continu- 


Of  Compression.  359 

ally,  his  features  were  distorted,  his  arms  and  fingers  stiffened 
and  crooked  with  cramps  and  spasms  :  his  condition  this  day  and 
evening  reminded  me  of  the  condition  of  boys  in  the  worst  stage 
of  acute  hydrocephalus  or  inflamed  brain.  At  ten  at  night,  he 
had,  alter  suffering  thus  violently  all  day,  subsided  into  a  sort 
of  stupor,  without  vomiting,  but  with  a  rapid  pulse. 

"  The  night  of  the  fourth  was  restless  and  miserable,  but 
much  of  it  he  passed  in  a  state  of  stupor  :  on  the  fifth  day  the 
swelling  of  the  forehead  had  entirely  flattened  ;  that  of  the  eye- 
lids was  gone  ;  nothing  remained  to  denote  the  place  of  injury, 
but  the  general  suggillation  of  blood  with  which  the  forehead 
and  eye-lids  were  discoloured  :  at  five  this  evening  I  found  him 
quite  sensible,  complaining  of  excruciating  pain  in  the  head, 
screaming  with  the  torture,  and  his  ejes  horriblv  distorted,  es- 
pecially the  right  one,  which  was  turned  downwards  and  in- 
wards till  the  iris  was  almost  hidden  under  the  inner  angle  of 
the  eve.  This  night  he  had  much  dtlirium,  and  while  conscious 
complained  of  pain  of  the  head,  especially  behind  the  ear;  for 
though  he  felt  pain  of  the  forehead  when  pressed,  he  felt  pain 
behind  the  ear  and  through  the  head  at  aU  times  :  he  howled 
much  this  night  from  eleven  o'clock,  and  his  thighs  were  rigid 
and  his  toes  crooked  with  the  spasms. 

"  On  the  sixth  I  found  him  dead  ;  he  had  raved  the  whole 
night  long,  had  cried  continually  with  the  pain  of  his  ear  and 
forehead,  was  seized  betwixt  two  and  three  in  the  morning  with 
such  universal  spasm,  squinting,  and  howling  as  he  had  on  the 
afternoon  of  the  third,  and  at  six  in   the  morning  he  expired." 

Here  was  no  symptom  of  extravasation  nor  of  compression  ; 
none  but  of  inflammation  ;  and  against  inflammation  what  could 
I  have  done  by  tearing  the  scull  with  the  trepan  ?  It  was  not 
for  want  of  those  marks  which  are  usually  thought  a  vindication 
by  those  who  are  impatient  to  apply  the  trepan,  that  I  refrained 
from  using  it,  for  I  distinctly  felt  a  fracture  in  the  forehead, 
accompanied  with  a  degree  of  depression  in  the  place  of  the 
frontal  sinus  :  but  from  a  perfect  consciousness  that  mv  opera- 
tion could  do  nothing  but  increase  the  inflammation,  and  from  a 
persuasion  that  the  fracture  was  a  concomitant  merely  of  a  more 
fatal  disease  ;  I  reflected  seriously,  and  found  myself  assured, 
from  the  symptoms,  that  inflammation  was  the  principal  dis- 
ease ;  that  fracture  at  this  point  could  be  attended  with  no  re- 
markable depression  ;  that  if  it  was  extensive,  it  must  run 
through  the  basis  of  the  scull ;  and  I  had  the  satisfaction,  me- 
lancholy though  it  was,  of  discovering,  on  dissecting  the  boy's 
head,  not  the  slightest  extravasation  upon  the  dura  mater,  but 
the  surface  of  the  brain  universally  reddened,  and  its  vessels 
turgid,  and  there   was  a   wide  fracture,  beginning  at  the  orbi- 


360 


Of  the  Operation  of  Trepan. 


tary  plate  of  the  frontal  bone,  and  running  quite  across  the  oc- 
cipital bone  into  the  <bramen  magnum  ;  but  without  any  remark- 
able appearance  either  under  the  bruised  part  of  the  forehead 
or  behind  the  ear. 

I  will  no  longer  detain  vou.  but  hasten,  after  a  short  section  on 
the  mechanical  part  of  your  duty,  on  the  operation  of  trepan,  to 
lay  down  rules  lor  your  general  conduct,  not  without  a  ronfi- 
dtmce  that,  among  the  varietv  of  delineations  of  the  disord<  red 
conditions  of  the  brain,  narrative  or  descriptive,  which  I  have 
laid  before  you,  you  will  be  able  to  fin  I  rational  parallels  for  a 
great  proportion  of  the  accidents  which  may  overtake  you  in 
your  future  practice. 


SECTrON    IV. 

Of  the  Operation  of  Trepan. 

At  the  head  of  this  little  chapter,  of  instructions  how  to  use 
ths  surgical  instruments,  I  have  placed  those  used  by  the  mo- 


Of  the  Operation  of  Trepan.  361 

dern  surgeon:*  if  you  conceive,  as  I  trust  you  do,  the  essen- 
tial purposes  of  the  operation,  I  have  no  fear  of  your  using 
them  with  sufficient  dexterity  and  address  ;  and  my  instructions 
on  this  head  shall  be  few,  plain,  and  simple. 

The  simple  form  of  the  modern  instrument  marked  (A)  turn- 
ing in  half  circles  with  the  hand,  is  found  to  perforate  quick 
enough,  and  to  be  extremely  manageable,  since  the  saw  is  ea- 
sily inclined  so  as  to  continue  its  semicircular  incision  on  that 
segment  or  side  of  the  perforation  which  is  least  cut.  The  for- 
ceps (B)  take  out  the  piece  of  bone,  either  by  their  circular  lips 
(C)  corresponding  with  the  circle  of  the  crown,  being  introdu- 
ced into  the  circular  cut  to  seize  the  sawed  piece,  or  by  the 
points  (D)  being  introduced  to  poise  it  out.  The  lever  (E)  is 
sometimes  useful  in  poising  out  the  piece  separated  by  the  saw, 
but  the  point  of  it  is  too  blunt  and  round  to  be  very  serviceable, 
in  any  but  its  proper  office,  which  is  to  poise  and  raise  up  what- 
ever depression  ot  the  scull  requires  to  be  elevated;  and  the  le- 
vator and  the  forceps  are  equally  used  in  twisting  or  poising  out 
loose  pieces  of  the  scull.  These  are  the  simple  instruments 
now  laid  in  the  operating  case  ;  along  with  which  you  are  usual- 
ly provided  with  a  brush  to  clean  the  teeth  of  your  saw  ;  a  se- 
cond head  or  crown,  of  the  same  diameter  with  the  first,  that 
while  the  one  is  blunted,  or  when  it  is  unscrewed  for  the  pur- 
pose of  being  cleaned,  the  other  may  be  used;  a  knife  is  also 
laid  in  the  case,  for  dividing  and  raising  up  the  scalp,  and  of- 
ten a  rug  in  e  or  triangular  instrument,  like  a  caulker's  iron,  for 
scraping  away  the  pericranium,  which  I  never  do,  for  I  find  it 
unnecessary,  and  do  not  think  it  right  or  safe. 

1.  For  the  disposition  of  your  Instruments  and  Dressings — 
They  are  to  be  laid  in  two  small  plates,  within  a  double  table- 
napkin,  the  napkin  being  pinned  so  over  the  bottom  of  the  plate 
that  it  may  not  shift,  nor  any  awkward  accident  happen :  on  the 
first  plate  is  deposited,  within  the  folds  of  the  napkin,  the  tre- 
phine, the  centre-pin  of  the  crown,  the  key  to  unscrew  it  with, 
the  lever,  the  forceps,  a  tooth-pick,  and  a  brush  ;  on  the  outside 
of  the  cloth  is  laid  a  knife  and  sponge,  soaked  and  squeezed, 
so  as  to  be  ready  for  use.  Or.  the  plate  of  dressings  are  to  be 
laid,  lint  nicely  folded  into  smaller  and  greater  compresses,  ve- 
ry soft ;  a  little  square  piece  of  oiled  lint ;  a  broad  compress  of 
four  or  six  folds  of  old  linen  ;  a  double-headed  roller,  three  ells 

"  l  have  added  to  Mr.  Bell's  figures,  a  reprefentation  of  a  faw,  recommended 
by  Mr.  Hey,  of  Leeds.  With  this  inttrument,any  particular  point  oi  bone  may 
be  cut  out,  and  it  has  this  very  great  advantage,  that  it  enables  you  to  remove 
mo  more  of  the  bone  than  is  abfolutely  neceffary.  !t  is  ufeful  on  many  other  occa- 
fions  for  the  removal  of  dt&afed  bone  :  (it  is  lure  reprcfented  half  its  proper  fize.^  ■"% 

2  Z 


362  Of  the  Operation  of  Trepan. 

long,  pinned  at  each  end,  so  that  when  lifted,  however  hastily, 
it  may  not  run  down  ;  and  in  the  cloth  that  covers  the  plate- 
should  be  stuck  one  or  two  needles  oi"  the  smaller  size,  threaded 
with  a  double  thread  waxed. 

2.  For  the  Posture  of  your  Patient — If  composed  and  sensi- 
ble, and  capable  of  sitting  erect,  you  should  place  him  on  the 
ground,  as  a  dentist  places  his  patient:  the  assistant,  who  is  to 
hold  him,  should  have  a  board  laid  across  his  thighs,  the  pa- 
tient's shoulders  fixed  between  his  knees,  and  the  patient  re- 
clining his  head  upon  a  pillow  laid  upon  the  board;  the  assist- 
ant should  lay  his  hands  gently  over  the  head  so  as  to  steady  it, 
and  in  such  a  manner  as  to  use,  without  change  of  posture, 
greater  exertions,  if  required :  where  the  patient  lies  insensible, 
he  should  be  moved  towards  the  side,  or  towards  the  head  of 
the  bed ;  his  head  laid  on  a  pillow,  steadied  by  a  board  under 
it ;  unless  the  couch  on  which  the  patient  chances  to  be  laid,  is 
sufficiently  firm  :  a  bed  never  is. 

3.  Jn  cutting  the  Integuments — The  first  step  of  your  opera- 
tion, you  lift  from  the  outer  cover  the  knife  and  the  sponge  ; 
the  sponge,  small  and  compressible,  you  hold  in  the  palm  of 
your  left  hand,  under  the  ring  and  little  fingers ;  you  lay  the 
mid-finger,  fore-finger,  and  thumb  of  the  left  hand  broad  upon 
the  scalp  ;  jou  feel  with  the  point  of  the  left  fore-finger,  and  by 
it  guide  your  knife  through  all  parts  of  the  incision.  First, 
If  the  scalp,  having  been  once  detached  to  a  great  extent,  is  re- 
united but  over  a  carious  bone  and  suppurating  brain,  the  hol- 
low integuments  admitting  the  probe  to  turn  to  a  great  extent 
over  the  diseased  scull,  you  take,  in  place  of  the  round  edged 
scalpel,  a  blunt  pointed  bistoury,  and  running  it  along,  you  at 
one  stroke  disengage  the  flap  of  diseased  integuments,  and  turn- 
ing it  down  see  the  whole  extent  of  the  dry,  yellow,  and  black- 
ened bone  :  your  perforation  should  be  central  in  respect  to 
such  caries.  Second,  The  scalp  having  risen  in  form  of  a  puffy 
tumour  over  a  contused  part  of  the  cranium,  you  make,  with 
the  round  edged  scalpel,  not  a  crucial  incision,  for  that  makes 
four  small  angles  in  the  scalp,  the  raising  up  one  or  more  of 
which  displays  but  little  of  the  diseased  bone,  but  an  incision  in 
a  tripod-like  form  ;  then  the  three  points  beir,g  dissected  away 
from  the  scull,  make  a  very  large  opening,  and  even  two  only  of 
the  points  being  raised,  they  make,  as  being  two  thirds  of  a  circle, 
a  very  free  opening  :  here  too  the  state  of  the  scull  marks  the 
danger  to  the  brain  ;  but  in  place  of  being  yellow,  rough,  or 
blackened,  it  is  usually  only  dry,  not  shining,  nor  brilliantly 
white,  not  attached  to  the  periosteum  or  integuments  ;  some- 
times it  is  spotted  or  tinged  with  yellow,  and  devoid  of  circu- 
lation, and  does  not  bleed  when  scraped  with  the  point  of  the 


Of  the  Operation  of  Trepan.  363 

knife.  Third,  When,  after  a  dreadful  fall,  the  scull  is  cruelly 
fractured,  pieces  beaten  in,  and  the  fissures  wide,  circumspec- 
tion is  so  natural,  and  you  can  so  distinctly  feel  with  the  point 
of  the  left  fore-finger  those  asperities  and  openings,  through 
which  your  knife  might  plunge  into  the  dura  mater,  that  I  need 
but  to  intimate  the  danger.  But,fourt/ihj,  When  from  a  des- 
perate fall  upon  the  steps  of  a  stone  stair-case  for  example,  the 
patient  lies  in  a  deadly  stupor,  cold,  pulseless,  moaning,  the  in- 
teguments never  rise  into  a  tumour,  nor  become  ecchymosed, 
except  very  slighdy ;  they  remain  entirely  flat  lor  days,  because 
the  man  is  almost  dead;  the  hemiplegia  alone,  with  some  slight 
blemish  on  the  scalp,  directs  you  on  which  side  to  operate,  viz. 
the  side  opposite  to  that  which  is  palsied,  and  from  the  con- 
vulsed or  dying  state  of  the  patient  you  must  do  so  quickly. 
The  surgeon  in  such  case,  operating  without  a  certain  know- 
ledge of  the  state  of  the  scull,  is  in  danger  of  plunging  his  knife 
unawares  through  a  wide  fracture.  1  have  witnessed  this  dis- 
aster ;  let  such  incisions  then  be  done  carefully. 

Allow  me  to  add  to  these  particulars  a  few  general  instruc- 
tions. Do  not  seek  to  pursue  the  several  limbs  of  a  fracture, 
for  to  these  your  operation  does  in  no  shape  relate  ;  but  seek 
the  central  point  only,  where  the  weapon  or  sharp  stone  has 
penetrated,  or  where  the  depressed  angle  is  kept  down  by  the 
firm  and  sound  bone.  Do  not  seek  to  scrape  the  bone,  that 
vou  may  trepan  easily ;  I  never,  in  amputation  or  in  trepan, 
found  the  soft  parts  entangle  the  teeth  of  the  saw :  in  trepan- 
ing,  I  only  cut  away  that  cellular  substance  into  which  the  ex- 
travasated  blood  is  strongly  injected,  sometimes  solidly  impact- 
ed, and  no  farther  than  to  procure  a  distinct  view  of  the  frac- 
tured pieces.  Do  not  lay  pieces  of  liut  on  the  integuments, 
entrusting  them  to  awkward  assistants  to  hold  them  back  while 
you  perforate;  for  it  is  the  sensibility  of  the  integuments  that 
makes  the  patient  cry,  resist,  and  struggle,  which  at  once  im- 
presses the  spectators  with  horror,  and  brings  the  reproach  of 
cruelty  on  the  surgeon,  who  must  complete  his  operation  in  the 
midst  of  such  cries:  if  you  would  avoid  this  unseemly  scene, 
use  spathulas  or  flat  plates  of  iron,  such  as  Mr.  Croker  King 
calls  defenders,  to  hold  aside  the  integuments,  and  the  perfo- 
ration, which  should  be  slowly  and  deliberately  performed,  will 
not  seem  tedious  nor  cruel.* 

In  perforating  the  Scull — Ascertain  first  the  place  most  fit 
for  perforation,  viz.  on  the  angle  of  depression,  and  in  the  line 


*  If  you  remove  the  pericranium  with  the  roitgitie  in  the  firft  iuftance,  and 
have  the  integuments  hekl  back,  your  patient  experiencing  no  ruin,  will  give  you 
no  trouble.     S. 


364  Of  the  Operation  of  Trepan. 

of  the  fissure  where  the  fissure  is  wide  and  gaping:  on  the  bro- 
ken  bone,  il  it  be  firm,  on  the  sound,  it  it  be  so  unsteady  as  not 
to  bear  the  pressure  of  the  centre-pin,  or  the  working  of  the 
saw ;  in  the  middle  of  the  carious  portion,  when  there  is  caries 
without  Iracture  ;  and  any  where  on  the  side  opposite  to  that 
paralysed,  but  especially  a  little  below  and  to  one  side  of  the 
centre  ot  the  parietal  bone,  when  there  is  reason  to  believe  the 
brain  oppressed  by  extravasation,  without  any  visible  injury  to 
mark  the  place. 

Lilt  first  the  crown  of  the  trepan  you  mean  to  apply ;  press 
it  firm  to  the  bone,  and  make  one  or  two  turns  in  order  to  mark 
the  centre  of  the  circle,  by  penetrating  with  the  centre- pin  a  lit- 
tle way:  next  dismount  the  trepan  head;  take  the  triangular 
perforator,  and  having  fixed  it  in  the  shaft,  bore  with  it  a  cen- 
tral hole,  for  the  centre-  pin,  deep  enough  to  hold  it  securely  while 
you  perforate :  then  mounting  the  crown  of  the  trepan  again, 
place  the  centre-pin  of  it  in  that  hole,  and  begin  to  saw  :  in  cut- 
ting with  the  trephine,  which  turns  in  half  circles,  observe  well 
the  way  in  which  the  teeth  are  set,  for  they  are  set  obliquely  ; 
you  may  be  turning  and  twisting  it,  and  that  very  vigorously, 
as  I  have  seen  some  surgeons  do,  without  cutting  more  than  a 
right-handed  person  would  pierce  a  cork  by  turning  a  left-hand- 
ed cork-screw  :  as  your  trephine  turns  but  half  circles,  you 
must  inevitablv  cut  deeper  on  that  side  of  the  circle  towards 
which  the  hand  turns  ;  you  must  therefore  probe  frequently 
(^specially  when  there  is  much  bleeding,  or  when  you  are  sen- 
sible of  having  cut  deep)  with  the  tooth-pick  ;  and  when  you 
feel  that  you  have  penetrated*  on  one  side,  change  your  pos- 
ture, turn  half  round  the  patient,  which,  by  giving  5  our  hand 
a  new  inclination,  sets  it  right  for  cutting  what  remains,  which, 
in  such  delicate  circumstances,  and  having  so  nearly  completed 
the  perforation,  must  be  cautiously  done  and  slowly. 

In  the  course  of  perforating,  while  you  probe  with  the  quill, 
you  give  the  crown  of  tht  trepan  to  your  assistant  to  be  brush- 
ed, or  to  be  altogether  changed ;  and  when  you  are  satisfied  of 
the  depth  of  your  perforation,  he,  in  returning  it  to  you,  wipes 
away  the  saw-dust  with  the  same  brush. 

I  seldom  have  completed  the  perloration,  never  have  got  out 
the  trepan  circle  sticking  in  the  crown  of  the  trepan,  but  have 
sometimes  poised  it  out  with  the  handle  of  the  scalpel,  or  the 

*  I  would  advifethe  furgeon  to  change  his  pofture  fcveral  times  when  he  thinks 
he  is  nearly  through,  fo  as  to  endeavour  not  to  have  the  Icull  thick  in  one  place 
and  per. orated  in  another,  but  try  to  cut  fo  uniformly  as  not  to  let  the  inftrument 
get  through  at  all;  but  when  the  whole  is  thin,  break  up  the  piece  with  the  ele- 
vator. For  where  the  dura  mater  adheres  clofely  to  tht  bone,  lie  will  be  very  apt 
*o  wound  it  it  he  fufiers  his  inftrument  to  cut  through.     S. 


Of  the  Operation  of  Trepan.  365 

pointed  extremity  of  the  forceps  marked  (D).  While  sawing, 
whether  in  trepaning  or  in  amputation,  never  think  to  over- 
come difficulty  or  resistance  by  pressure,  but  when  you  feel  op- 
position, cut  lightly,  and  turn  the  saw  nimbly,  lighten  your  hand 
when  it  threatens  to  stop  ;  never  in  sawing  a  long  bone  expect 
to  loosen  the  saw  by  pushing  and  wriggling,  but  by  withdraw- 
ing it,  nor  in  trepaning  by  pressing  onwards,  but  by  turning 
the  trephine  halt  round  backwards.  Choose  trepan  crowns  with 
the  sides  grooved  and  sharpened,  as  well  as  the  points  of  the 
teeth,  for  that  kind  of  saw  cuts  wider  as  it  goes  deeper,  and 
works  the  whole  circle  of  the  bone  large  and  lree  ior  the  trepan 
to  move  in. 

5.  In  respect  to  the  Object  of  the  Perforation — You  will  find 
that  extravasated  blood  rolls  out  spontaneously,  in  black  and 
firm  clots,  through  the  trtpan  hole  ;  and  from  dressing  to  dress- 
ing is  easily  hooked  out,  with  an  armed  probe,  or  washed  out 
with  tepid  wat»  r,  the  dura  mater  coming  gradually  into  closer 
contact  with  the  scull:  pus  flows  out  still  more  easily,  and  mul- 
tiplied operations  for  either  purpose  (ol  letting  out  blood  or  pus) 
are  extremely  imprudent;  to  repeat  the  perforation  is  some- 
times necessary,  on  account  of  a  great  depression  attended  with 
manifest  danger,  where  the  edges  of  the  depressed  portion  are 
fast  locked  under  projecting  corners  of  the  firm  scull,  and  the 
lever  being  introduced  first  into  one,  then  into  the  other  perfo- 
ration, tfffe  depression  is  raised,  but  never  without  great  iorce, 
usually  a  loud  noise,  and  sometimes,  as  I  have  argued,  with 
unjustifiable  violence,  insomuch  that  on  many  occasions,  espe- 
cially where  the  depression  it  flat,  extensive,  and  having  proba- 
bly no  offending  points,  I  would  rather  leave  it  unreduced: 
unless  in  depressions  of  a  singular  and  dangerous  form,  punc- 
tured fractures,  and  those  where,  from  their  peculiar  iorm, 
there  is  strong  reason  to  suspect  spicule,  I  am  not  curious  a- 
bout  depressions,  nor  over- anxious  in  raising  every  point. 

6.  In  reaped  of  Dreasings — I  would  intreat  you  to  consult 
your  own  good  sense,  rather  than  hearken  to  the  common  igno- 
rant advice  of  laying  merely  a  piece  of  oiled  lint  on  the  wound, 
and  over  that  a  poultice.  The  old  practice  of  cutting  a  circular 
piece  of  cloth  as  a  syndon,  and  cramming  it  under  the  scull  to 
support  the  brain,  and  leave  room  for  matter  and  blood  flowing 
out,  I  entirely  disapprove  of,  but  neither  can  I  approve  ol  leav- 
ing it  quite  unsupported  ;  in  short,  I  dress  the  trepaned  scull, 
as  I  do  every  other  wound,  nicely  and  carefully  :  first,  I  lay  the 
edges  of  the  scalp  smoothly  together,  sometimes  stitching  it 
with  one  or  two  points  of  the  needle  ;  then  I  lay  upon  it  a  sm.tll 
pledget  of  oiled  lint  ;  next  a  small  and  rather  firm  compress  of 
lint;  next  a  general  compress  over  the  whole  of  that  side  oi  the 


366  Rules  of  Practice. 

head ;  and  finally,  I  roll  the  head  gently,  but  steadily  and  some- 
what firmly,  with  a  broad  roller,  and  put  over  that  a  thin  linen 
cap,  lightly  tied  under  the  chin. 

I  allow  no  poulticing,  except  what  is  necessary  to  bring  off  the 
first  dressings ;  and  no  washing  nor  curious  cleansing  of  the 
wound,  which  I  wipe  slightly,  and  dress  with  very  little  oint- 
ment, almost  dry :  when  blood  still  exudes,  that  makes  an  ex- 
ception, being  a  special  case  ;  and  when  a  fungus  threatens  to 
protrude,  and  even  where  only  the  sound,  but  granulating  dura 
mater  projects  through  the  trepan  hole,  I  find  it  necessary  some- 
times to  depress  the  dura  mater,  or  push  aside  the  fungus,  to 
let  the  matter,  confined  from  dressing  to  dressing,  flow  out ; 
then,  contrary  to  my  usual  practice,  1  think  it  right  to  dress- 
morning  and  evening. 

When,  in  the  course  of  the  cure,  fungus  protrudes  and  fills 
the  opening,  and  the  confinement  of  matter  causes  stupor  and 
hemiplegia,  and  the  inflammation  of  the  brain,  cries  and  con- 
vulsions, I  reckon  my  patient  lost :  but  I  am  proportionally 
more  diligent  in  my  methods  of  procuring  a  free  efflux  of  the 
matter,  and  I  think  it  better  to  shave  off  the  protruding  fungus 
than  to  apply  escharotics,  which  I  have  usually  found  hurtful. 

It  is  invariably  found  that  noise,  heat,  wine,  passion,  and  other 
exciting  causes,  pre  fatal  to  those  who  have  suffered  the  opera- 
tion of  trepan  :  the  confusion  of  a  storm,  after  a  battle  at  sea  ; 
the  renewal  of  the  engagement ;  the  hour  of  firing  thfc  batteries 
in  a  besieged  city  ;  the  intrusion  of  unwelcome  visitors  in  the 
chamber  of  a  private  person ;  quarrels,  intemperance,  or  venery, 
have  in  many  instances  brought  on  inflammation  of  the  brain, 
such  as  has  proved  fatal  to  those  far  advanced  in  their  recovery 
after  this  dangerous  operation  ;  therefore  let  them  be  kept  low, 
still,  quiet,  with  a  loose  belly,  a  perspirable  skin,  little  light,  and 
few  visitors,  and  no  conversation  but  such  as  is  composing  and 
cheerful. 

section  v. 

Aphorisms,  or   Rules  of  Practice,  deduced  from  the  foregoing 
Discourses. 

We  have  examined  in  detail  every  point  of  practice,  and  are 
now  arrived  at  the  conclusion  of  these  discourses,  in  which  it 
is  natural  to  recapitulate  whatever  is  important,  and  ascertain 
whatever  rules  should  particularly  dwell  upon  your  memory. 
This  task,  could  I  entirely  acquit  myself  of  prolixness  in  these 
discourses,  might  be  spared;  yet  it  will  be  useful,  I  doubt  not, 
to  explain  in  short  aphoristic  rules  what  an  experienced  surgeon 
would  naturally  do  in  any  given  case. 


Rules  of  Practice.  367 

1.  Above  all  things  I  counsel  you  to  beware  of  precipitation  ; 
the  onl)  fault  which  can  incline  the  surgeon  to  conceal  the  cir- 
cumstances of  his  private  practice,  or  leave  upon  his  mind  any- 
lasting  unhappiness  :  I  entreat  you  on  every  new  occurrence,  to 
think  deliberately,  judge  soberly,  and  act  gently,  however  ur- 
gent a.case  may  seem,  be  in  no  haste  to  operate,  take  time  to 
consult,  and  rest  assured  that  nature  will  olten  perform  a  cure 
while  you  are  deliberating  upon  an  operation  ;  be  also  assured 
that  you  can  never  fail,  in  the  worst  cases,  to  foresee  the  pa- 
tient's death,  by  his  coldness,  paleness,  convulsive  motions,  aad 
involuntary  stools  :  if  these  signs  have  not  yet  appeared,  you 
have  time  for  a  few  hours  deliberate  reflection,  il  they  are  al- 
ready begun,  you  have  then,  least  of  all  any  motive  for  preci- 
pitate measures,  you  are  surely  too  late,  the  patient  must  die. 

2.  Fractures  and  injuries  of  the  head  are  more  frequent  in 
public  hospitals,  where  the  friends  ot  the  patient,  or  the  spec- 
tators of  any  unfortunate  accident,  leave  him  all  most  inanimate, 
perhaps  with  only  some  slight  apparent  injury  of  the  head, 
while  there  is  some  serious  damage  to  the  brain,  the  nature  of 
which  you  are  ill  able  to  develop,  without  knowing  how  the 
patient  was  struck,  or  where  he  fell  :  let  your  first  step  be  to 
collect  the  friends  or  spectators,  and  inquire  into  the  circum- 
stances of  the  fall  or  blow.  Let  it  be  an  especial  rule  with  you, 
never,  in  these  cases,  to  do  any  thing  precipitate  or  rash. 

3.  Every  man  of  prudence  and  discretion,  while  he  exam- 
ines the  wound,  and  reasons  on  the  symptoms,  inquires  into 
the  circumstances  in  which  the  patient  was  hurt :  whether  by 
a  fall  or  by  a  blow,  whether  when  he  fell  he  was  drunk  or  so- 
ber, helpless,  and  pitching  headlong,  or  in  his  senses,  aware  of 
his  danger,  and  by  extending  his  arms  breaking  the  force  of  the 
fall :  whether  he  pitched  headlong  over  a  rail,  or  tumbled  down 
stairs,  touching  each  step  ;  whether  he  fell  on  plain  ground,  or 
on  a  declivity,  and  if  he  received  a  blow,  whether  he  was  struck 
by  accident  or  by  design  ;  at  arms  length  or  close ;  with  a  hea- 
vy weapon  or  with  a  sharp  one  ;  by  a  feeble  man  or  a  strong  ; 
by  a  drunken  man  without  aim  or  force  or  bv  an  angry  man, 
in  the  height  of  rage  and  with  full  effect. 

4.  There  are  certain  kinds  of  accidents  which  import  danger, 
each  according  to  its  peculiar  nature  ;  as  a  concussion,  a  con- 
tusion,   A    WOUND    WITH     A    SHARP    WEAPON,    A    PUNCTURED 

wound.  Writers  on  jurisprudence  have  long  distinguished 
these  kinds  of  wounds,  of  which  the  danger  is  in  some  imme- 
diate, while  in  others  it  is  deferred  till  the  fortieth  or  till  the 
hundredth  day,  and  have  been  accustomed  to  affirm  that  the 
more  the  scull  is  fractured  tae  less  the  danger,  the  breaking  of 
the  scull  deadening  the  force  of  the  blow.     Of  all  the  quaint 


368  Rules  of  Practice. 

reasons  which  authors  have  given,  not  one  is  true  ;  but  yet  it  is 
a  fact,  that  the  man  who  has  an  extensive  fracture  of  the  scull 
escapes,  while  he  who  has  no  fracture  dies.  It  is  not  because 
the  yielding  of  the  bone  lessens  the  force  of  the  blow  upon  the 
organ  which  that  bone  protects,  but  because  concussion  is  a  more 
dangerous  injury  than  fracture,  even  though  accompanied  with 
deep  depression  of  the  scull :  there  is  great  danger  in  the  case 
of  concussion,  though  there  be  no  fracture !  there  is  little  com- 
parative danger  in  fracture  when  there  is  no  concussion  !  when, 
from  the  nature  of  the  fall,  the  concussion  is  great,  no  degree 
of  fracture  can  lessen  the  danger,  for  the  danger  lies  in  the  con- 
cussion or  injury  of  the  brain  which  is  produced  by  a  fall,  not  in 
fracture,  which  affects  only  the  scull,  and  is  occasioned  by  the 
blow.  If  a  mason  fall  from  the  tiles  of  a  house,  or  a  sailor  from 
the  yards  or  rigging  of  a  ship,  and  fracture  his  scull,  the  great- 
ness of  the  fall  lessens  in  no  degree  the  violence  of  the  concus- 
sion ;  the  extent  of  the  fracture  marks  rather  a  probable  con- 
cussion, of  which,  if  it  be  great,  the  patient  dies:  but  if  the  tiles 
fall  upon  the  mason,  or  the  sailor  is  knocked  down  by  the  fall- 
ing of  a  block  and  tackle,  a  great  fracture  does  not  cause  an 
equal  degree  of  injury,  much  less  if  he  is  knocked  down  with 
an  handspike,  and  still  less,  if  his  scull  be  cut  with  a  cutlass ; 
the  fracture  may  be  in  such  cases  great,  and  the  concussion  and 
consequent  danger  slight:  in  short,  the  scull  is  most  fractured 
by  those  blows  which  are  least  injurious,  and  least  injured  by 
those  general  shocks  which  cause  the  most  dangerous  concus- 
sions and  extravasations  in  the  brain. 

5.  As  a  bruise  is  worse  than  a  wound,  and  a  sprain  or  lux- 
ation of  a  limb  more  distressing  in  its  consequences  than  a  frac- 
ture, so  is  concussion  of  the  brain  more  dangerous  than  wounds 
or  fracturrs  of  the  scull :  to  the  distinctions  1  have  hinted  at,  I 
should  wish  to  remind  you  of  one  which  I  have  remarked :  if 
by  a  fall  your  patient  lie  in  a  state  of  stupor,  it  may  be  from 
Concussion :  if,  after  a  smart  blow  with  a  bludgeon,  not  heavy 
nor  depriving  the  patient  instantly  of  his  senses,  it  must  be  from 
extravasation. 

6.  It  is  not  with  every  kind  or  degree  of  stupor  that  an  ex- 
perienced surgeon  is  alarmed,  he  is  accustomed  to  distinguish 
many  kinds,  as  well  as  degrees,  of  that  affection :  the  stupor 
may  be  that  of  intoxication,  which,  by  the  smdi  and  the  vo- 
miting, he  is  often  able  to  distinguish,  and  never  is  afraid  to 
leave  the  head  of  the  patient  untouched  till  the  longest  period 
of  intoxication  (if  it  be  intoxication)  and  all  its  consequences 
have  expired  ;  or  it  may  be  that  of  slight  concussion,  which,  be- 
ing attmded  with  no  oppression  of  pulse,  nor  suspension  of 
breathing,  is  soon  resolved  by  the  natural  lorce  of  the  circula- 


Rules  of  Practice.  369 

tion  :  or  it  may  be  that  stupor  which,  in  old  age,  generally  fol- 
lows a  blow  or  fall,  without  indicating,  as  far  as  I  have  observ- 
ed, any  permanent  injury:  but  if  the  .stupor,  though  slight,  is 
accompanied  with  vomiting,  and  a  slow  intermitting  puke,  there 
is  reason  to  apprehend  the  most  imminent  danger. 

7.  Nor  does  every  degree  or  kind  of  delirium  alarm  him  : 
delirium,  arising  after  stupor,  is  a  favourable  sign  :  a  wound  of 
the  scalp  is  often  followed  by  erysipelatous  szvelling,  and  a  short 
and  harmless  delirium  :  a  patient  thrown  into  an  hospital  with 
wound  of  the  scalp,  is  often  seized  with  sudden  rigours,  vo- 
miting, high  fever,  and  delirium,  but  these  are  the  symptoms 
of  hospital  fever  merely,  and  might  as  well  be  superinduced  af- 
ter a  wound  of  the  finger,  as  alter  a  wound  of  the  scalp:  one 
who  has  formerly  suffered  much  from  fevers,  or  who  has  been 
insane,  is  more  apt,  as  I  have  known  in  several  instances,  to 
awaken  in  a  state  of  phrenzij,  alter  lying  son>e  time  under  the 
stupor  of  a  blow  :  these  are  not  dangerous  cases  of  delirium  ; 
and  though  stupor,  insensibility,  rigour's,  and  other  marks  of 
suppuration  or  of  effusion  of  blood,  may  be  motives  for  apply- 
ing the  trepan,  delirium,  as  far  as  I  can  recollect  or  imagine, 
never  is. 

8.  I  believe  the  danger  to  be  prognosticated  is  very  nearly  in 
this  gradation  :  Stupor,  though  deep,  and  to  the  tvro  seemingly 
very  dangerous,  is  not  a  cause  of  immediate  alarm  to  the  expe- 
rienced surgeon  :  Delirium,  succeeding  such  stupor,  shows  that 
the  vascular  action  is  begun,  and  the  oppression  at  an  end. 
Slighter  somnolency,  free  from  stupor,  in  which  the  patient  has 
his  senses,  (though  inclined  to  sleep)  but  with  a  heavy,  op- 
pressed, and  intermitting  pulse,  is  extremely  alarming,  and  re- 
quires the  trepan:  Stupor,  accompanied  with  dilated  pupil,  and 
palsy  of  one  side,  indicates  the  most  imminent  danger,  yet  such 
as  is  often  relieved  by  the  trepan.  Stupor,  in  which  the  face  is 
pale,  the  extremities  cold,  the  pulse  not  heavy  and  labouring,  but 
quick  and  flittering,  especially  il  attended  with  palsy  of  one  side, 
or  slight  convulsions  agitating  the  features  or  the  limbs,  is  a  state 
altogether  to  be  despaired  of:  vet  perhaps  it  is  even  here  our 
duty  to  operate,  but  without  hope. 

9.  The  prognostics  from  tumours,  I  must  remind  von  are 
still  more  interesting;  for  any  peculiarity  in  the  tumour  indi- 
cating the  death  of  the  bone  below,  more  certainly  loretcls  dan- 
ger to  the  brain  than  the  most  formidable  fracture  :  First, 
Where  the  scalp  merely  is  wounded,  perhaps  punctured,  but  no 
tumour  ensues,  the  patient  is  often  affected  with  spasms  in  the 
face,  and  the  most  ludicrous  contortions  of  the  mouth  ;  this  is 
a  symptom  much  resembling  that  contraction  which  follows  the 
wounding  of  a  nerve  in  bleeding,  and,  like  it,  requires  an  incU 

3  A 


370  Rules  of  Practice. 

sion.  I  have  at  this  moment,  under  my  care,  a  little  boy,  of 
ten  years  old,  who,  having  fallen  over  a  stair-case  in  swarming 
the  baluster,  was  taken  up  apparently  dead,  has  lain  for  two 
da\s  in  a  state  of  deep  stupor,  is  now  entirely  recovered  from 
it ;  he  has  his  mouth  turned  more  entirely  to  one  side  than  I 
ever  saw  it  in  a  paralytic,  and  though  able  to  run  about  among 
his  play-iellows,  does  not  expose  himself  among  them  ;  this,  I 
have  promised  confidently,  (because  1  have  olten  seen  it)  will 
go  off — Secondly,  Erysipelas  often  seizes  the  scalp  after  slight 
wounds,  extends  over  the  face  and  ears,  closes  the  eye-lids,  is 
attended  with  smart  inflammatory  fever  and  delirium,  but  sub- 
sides in  a  few  days. —  Thirdly,  A  bloody  effusion,  if  the  blood 
be  in  great  quantity  and  the  effusion  permanent,  is  sometimes 
dangerous  to  the  scull  ;  but  I  must  remind  you  of  a  danger  of 
another  nature,  viz.  of  a  feeling  as  if  of  depression  of  the  scull, 
so  particular  that  even  the  experienced  are  apt  to  be  deceived : 
but  an  experienced  surgeon  is  in  no  haste  to  make  incisions  into 
such,  tumour,  even  though  the  patient  is  vomiting,  and  in  a 
state  of  stupor  ;  these  usually  are  but  the  first  consequences  of 
the  injury,  and,  like  the  tumour,  vanish.  I  have  seen  extrava- 
sation so  extensive  as  to  fluctuate  from  ear  to  ear,  and  yielding 
so  as  to  admit  the  finger  to  feel  depression  of  the  bone,  yet  the 
whole  has  been  absorbed. — Fourthly,  The  most  portentous 
tumour  is  the  least  formidable  in  appearance  ;  for  it  is  one  which 
proceeds  neither  from  extravasation  nor  inflammation  ;  it  is 
neither  red,  inflamed,  fluctuating,  nor  extensive,  but  arising 
from  the  death  of  the  cellular  substance  next  the  bone,  and  from 
the  impossibility  of  the  dead  surfaces  renewing  their  adhesion, 
thence  it  is  Emphysematous, puffy,  small,  circumscribed,  not  pain- 
ful :  is  accompanied  with  rigours  or  febrile  shiverings,and  start- 
ing or  nervous  tremblings  ;  confusion  of  head,  and  feebleness 
of  body  and  mind  :  it  is  the  most  desperate  disorder  with  the 
slightest  symptoms  :  suppuration  of  the  dura  mater  is  begun, 
and  if,  upon  the  slightest  intimation  of  this  kind  of  danger,  the 
patient  be  not  trepaned,  he  dies. 

10.  As  your  preceptor,  I  am  much  more  jealous  of  your  be- 
ing found  wanting  in  judgment  than  in  skill:  your  operations, 
I  doubt  not,  will  be  performed  with  address,  but  I  am  truly 
anxious  that  your  address  should  be  reserved  for  occasions  of 
real  danger,  and  that  the  powers  of  nature  should  never  be  an- 
ticipated nor  interrupted,  by  any  rashness  of  yours. — First, 
be  not  too  confident  in  promising  a  speedy  recovery;  even  in 
slight  and  cutaneous  wounds,  for  the  bone,  though  not  wound- 
ed, may  be  deadened  by  the  blow;  but  lay  the  edges  together, 
and  stitch  them  lightly  and  gently  to  procure  re-union:  dress 
the  wound  dry   with   lint,   court-plaster,  and   a  sprinkling  of 


Rules  of  Practice.  .371 

hair-powder,  which,  by  caking  with  the  blood,  keeps  the  edges 
of  the  wound  in  close  and  nice  contact  :  and  watch  your  pa- 
tient's condition  constantly,  especially  where  the  wound  has 
been  made  with  a  bludgeon,  a  stone,  or  any  blunt  and  heavy 
body. — Second,  be  not  afraid  of  an  open  though  apparently  a 
desperate  wound,  even  when  the  scull  is  cut  or  fractured,  even 
"  where  the  splinters  of  it  lie  pashed  upon  the  dura  mater  :" 
there  is  in  such  a  case  undeniable  danger,  since  the  bone  is 
wounded  and  all  the  parts  inflamed  which  defend  and  lie  in 
contact  with  the  brain  ;  but  such  open  wound,  though  wide,  is 
often  less  dangerous  than  a  slight  contusion  ;  it  is  but  a  com- 
pound fracture  of  the  scull,  and  you  have  no  warrant  for  doing 
any  thing  which  you  would  not  do  in  a  compound  fracture  of  any 
other  part.  I  spoke  of  Paree's  operation  on  Captain  Hydron, 
and  of  bone  re-uniting  with  bone,  I  meant  but  to  illustrate  a 
general  doctrine,  not  to  announce  a  rule  of  practice  :  I  advise 
you,  to  pick  away  carefully  every  lragment  of  the  scull,  to  dis- 
sect away  whatever  little  fragments  you  may  find  adhering  to 
the  scalp,  and  to  lay  down  soft  and  sound  integuments  only 
upon  the  wounded  scull  and  exposed  dura  mater. —  Lh'ird,  be 
not  careless  of  cleansing  the  scalp  and  laying  it  nicely  and 
smoothlv  down,  because  of  my  having  proved  to  you  that  rag- 
ged integuments  or  scalp  having  even  its  inner  surface  ingrain- 
ed with  mud  and  dirt,  has  adhered,  for  such  proofs  were  but 
meant  to  illustrate  a  general  principle,  to  show  how  tenacious 
both  the  scull  and  integuments  are,  of  life  and  circulation  :  to 
lay  them  down  ragged  or  foul  were  the  height  of  presumption, 
and  a  most  culpable  carelessness  ;  pick  the  surfaces,  cleanse 
them  with  the  sponge,  do  every  thing  to  entitle  you  to  success  ; 
when  you  stitch  the  lacerated  parts  together,  do  it  lightly,  and 
dress  the  edges  dry  ;  do  not,  in  your  anxiety  to  cleanse  them 
from  sand  or  mud,  wrap  the  head  in  a  poultice,  expecting  to 
unite  the  parts  after  suppuration  is  begun,  for  after  suppuration 
they  curl  backwards  and  retract ;  they  never,  as  far  as  I  have 
^een,  can  be  laid  together  again,  but  heal  with  a  gap  equivalent 
to  an  actual  loss  of  substance :  having  stitched  the  integuments, 
watch  the  state  of  the  wound  diligently,  and  the  instant  you  ob- 
serve the  stitches  overstrained  by  the  swelling  of  the  scalp,  or 
can  perceive  th.it  matter  is  confined,  the  bone  bare,  and  the 
probe  admitted  under  the  diseased  scalp,  lay  the  wound  open, 
and  then  use  a  poultice,  and  wait  patiently  the  granulation  of 
the  naked  bone,  or  the  sivms  of  internal  suppuration,  to  direct 
your  future  steps. — Fourth,  be  upon  your  guard  against  the  ir- 
retrievable fault  of  making  incisions  into  the  integuments  when 
they  are  entire,  however  distinctly  you  feel  a  fracture  or  de- 
pression through  them,  for  it  is  wonderful  how  happily  the  hurt 


372  Rules  of  Practice. 

parts  heal  and  the  extravasation  of  blood  is  resolved  when  the 
parts  are  kept  entire  ;  the  making  an  incision  in  such  a  case  is 
converting  a  simple  into  a  compound  fracture,  with  all  the  dan- 
gers of  it  ;  nothing  can  vindicate  you  in  taking  such  a  step  but 
the  most  unequivocal  proofs  of  a  concomitant  extravasation  of 
blood  ;  viz.  oppression,  somnolency,  a  heavy  pausing  pulse, 
a  dilated  pupil,  and  palsv  of  one  side  :  make  such  incision  (the 
integuments  I  mean  being  uninjured)  only  after  great  delibera- 
tion in  adults,  and  in  boys  never,  or  almost  never.* — Fifth,  be 
not  too  rash  in  entering  upon  an  operation,  merely  because  the 
patient  lies  in  a  state  of.  stupor  or  breaks  out  into  delirium; 
these  are  the  cases  which  least  frequently  require  the  trepan : 
and  when  you  are  entered  upon  an  operation,  be  not  too  parti- 
cular in  raising  every  point  or  piece  of  bone  that  either  seems 
or  is  really  depressed :  but  above  all,  be  not  too  late  in  opera- 
ting when  there  is  reason  to  suspect  a  suppuration  of  the  dura 
mater  ;  make  it  a  principle,  whatever  the  occasion  may  be  for 
vising  the  knife  or  saw,  to  be  sparing  of  the  integuments,  for 
the  loss  of  them  affects  the  scull,  to  be  still  more  sparing  of  the 
scull,  for  it  supports  the  dura  mater,  and  to  think  with  the  ut- 
most reluctance  of  puncturing  the  dura  mater  strong  as  the  sus- 
picions may  be  of  blood  being  extravasated  under  it,  for,  like 
a  second  scull,  this  firm  and  strong  membrane  supports  the 
brain  after  perforation,  and  when  it  is  punctured  the  brain  is 
deprived  of  all  support,  and  I  have  never  failed  to  see  it  pro- 
trude :  I  will  not  disguise  from  you  that  this  operation  of  punc- 
turing the  dura  mater  is  sometimes  successful,  that  it  is  report- 
ed so  by  creditable  authors,  but  it  is  my  duty  to  inform  you 
that  I  have  always  found  it  fatal. 

11.  In  respect  to  the  medical  treatment  of  your  patient,  I 
must  remind  you,  that  the  first  moment  of  stupor,  coldness, 
and  paleness,  requires  cordials  ;  but  the  reaction  that  follows, 
requires  that  the  powers  of  the  circulation  should  be  repressed  : 
and  I  must  also  remind  you,  that  such  accidents  happen  chiefly 
to  workmen,  vigorous,  strong,  and  healthy,  full  of  blood,  and 
often  in  the  prime  of  life,  that  though  there  are  many  who  bold- 
ly deny  the  use  of  bleeding,  they  speak  from  theory,  while 
none  dare  neglect  it  who  are  acquainted  with  practice  :  many 
times  the  patient  lifts  his  eyes  and  moves  his  limbs  while  the 
blood  is  yet  flowing  from  the  vein,  and  many  are  thus  recover- 
ed who  otherwise  would  never  move  them  again  :  bleeding  is 
useful  in  all  contusions,  falls,  and  blows,  to  arrest  the  progress 
of  extravasation ;  but  where  extravasation  has  already  taken 
place,  and  one  side  is  palsied,  blood  should  not  be  too  profuse- 

*  See  note,  page  329. 


Of  Tumours.  273 

ly  drawn  away,  lest  the  strength  suddenly  sink  :  the  brain  be- 
ing already  compressed  and  the  vital  powers  low,  it  is  peculiar- 
ly dangerous  to  draw  away  much  blood.  In  concussion,  which 
is  an  apoplectic  state  of  the  brain,  consisting  at  once  in  fulness 
of  vessels  and  general  exudation,  bleeding  relieves  the  oppres- 
sion and  promotes  absorption  :  in  stupor,  with  a  heavy  pulse, 
throbbing  gradually  stronger  and  stronger,  and  increasing  at  the 
same  time  in  velocity,  bleeding  must  be  used  to  prevent  the 
reaction  rising  to  delirium  ;  and  when  delirium  actually  rages, 
and  the  patient  starts  from  his  bed,  and  strikes  and  struggles,  it 
is  most  eminently  required  to  save  the  organization  of  the  brain 
from  the  intense  action  of  its  own  vascular  system  :  frequent 
bleedings,  drastic  purges  of  calomel,  and  cold  applications,  and 
cool  air,  are  useful ;  blisters*  and  opium,  doubtful  in  their  op- 
eration :  and  all  other  stimulants,  as  wine,  volatile  alkali,  &c. 
quite  improper. 


DISCOURSE  XX. 


ON  TUMOURS. 


SECTION    I. 

Preliminary  Observations. 

IT  is,  I  am  persuaded,  my  first  duty  to  display  the  importance 
of  this  department  of  our  science,  and  to  interest  your  sympa- 
thy and  reason  in  behalf  of  those  who  are  afflicted  with  tumours  ; 
of  which,  though  some  are  harmless,  far  the  greater  number, 
by  their  cancerous  or  malignant  nature,  by  oppressing  the  or- 
rans  of  breathing  and  swallowing,  by  destroying  the  bones,  or 
even  affecting  (when  seated  en  the  head  or  in  the  nostrils)  the 

*  2iiftcr9  arc  ftrcogly,  and  I  think  julily  recommended  by  Mr.  Abernethy.     S. 


374  Of  Tumours. 

functions  of  the  brain  itself,  bring  the  patient,  and  that  too  in 
the  vigour  and  prime  of  life,  to  an  untimely  grave.  In  each 
subdivision  of  our  subject  I  shall  have  occasion  to  lay  before 
you  examples  of  neglected  and  fatal  tumours,  of  dismal  scenes 
which  the  surgeon  did  not  dare  to  prevent  ;  of  operations  rash- 
ly begun,  and  abandom  d  in  the  very  moment  of  execution  ; 
we  need  not  seek  for  sad  and  persuasive  examples  of  such  dan- 
ger to  impress  the  importance  of  the  subject  upon  our  minds, 
nor  strive  to  recollect  minutely  the  long-continued  sufferings  of 
those  who  have  died  of  tumours.  The  scenes  we  have  wit- 
nessed in  Hospitals,  or  in  private  practice,  return  to  the  ima- 
gination from  time  to  time,  accompanied  with  all  thi  ir  tragical 
circumstances  ;  we  recollect  the  sufferings  of  our  patients,  and 
we  also  remember  that  the  most  loathsome,  painful,  and,  in  the 
end,  fatal  tumours,  were  once  trivial ;  we  also  know  that  thou- 
sands, at  this  present  time,  are  verging  towards  that  hopeless 
desperate  state,  from  which  even  the  most  intrepid  surgeon  will 
not  attempt  their  rescue,  at  the  peril  of  his  reputation  and  eter- 
nal peace  of  mind. 

Tumours  are  the  most  frequent  of  all  surgical  diseases  ;  eve- 
ry surgeon  must  find  the  treatment  of  tumours,  a  part  of  his 
daily  practice :  a  tumour,  in  whatever  part  of  the  body  it  is 
seated,  requires  an  intimate  acquaintance  with  the  structure  of 
that  part,  and  a  clear  recollection  of  all  the  precedents  or  rules 
which  mav  serve  either  to  direct  the  judgment,  or  to  guide  the 
hand.  The  surgeon  should  know  how  to  resolve  a  tumour,  or 
to  excite  it  to  suppuration ;  how  to  evacuate  the  matter,  and  ob- 
literate the  sac  ;  when  to  suffer  the  mild  and  harmless  to  grow, 
and  how  to  extirpate  at  every  risk  that  which  is  prone  to  ulce- 
ration or  cancer.  Every  tumour  is  a  subject  of  new  and  anx- 
ious consultation,  and  every  operation  of  this  irregular  nature, 
demands  a  knowledge  of  blood-vessels  and  nerves  not  easily 
remembered,  and  perhaps  no  where  trulv  described. 

Need  I  remind  you  what  torture  a  skilful  surgeon  may  pre- 
vent, what  misfortunes  ignorance  may  cause  ?  Do  we  not  see 
surgeons  mistaking  tumours,  malignant  in  their  nature,  for  indo- 
lent and  harmless  swellings  of  the  glands  ?  By  tormenting  a 
simple  tumour  it  may  become  malignant, — by  neglecting  a 
moveable  tumour  it  may  become  fixed, — by  allowing  a  small.and 
seemingly  harmless  tumour  to  grow,  it  may  wax  to  so  great  a 
size,  and  a;  quire  such  intimate  connections  with  the  more  im- 
portant vessels  and  nerves  as  to  defy  all  kind  of  surgery. 

Look  well,  then,  to  the  nature  and  probable  consequences  of 
every  tumour  ;  for  a  tumour,  though  void  of  any  character  of 
peculiar  malignity,  will,  if  seated  in  the  passages  of  the  nose 
or  the  throat,  on  a  bone,  or  in  connection  with  great  vessels  or 


Of  Tumours.  375 

nerves,  have  all  the  ill  effects  of  a  malignant  tumour  without 
being  so,  by  bringing  caries  upon  the  bones,  causing  disease  and 
ulceration  in  the  nostrils,  compressing  the  throa  ,  and  weaving 
in  its  roots  with  the  great  vessels  and  nerves,  and  from  this  uni- 
versal fact  results  this  incontrovertible  rule  of  practice,  "That 
no  suspicious  tumour,  seated  in  a  dangerous  part,  should  be 
permitted  to  grow."  Secondly,  That  almost  every  tumour, 
though  seemingb  indolent  in  its  nature,  has  its  period  of  ulcera- 
tion. A  tumour  of  mere  fat,  a  tumour  in  which  the  adipose 
membrane  is  alone  diseased,  a  steatomatous,  or  an  ulcerous  tu- 
mour in  which  is  collected  an  increased  secretion,  partly  fluid 
and  partly  solid,  or  purely  of  fat,  is  indeed  harmless,  unless  by 
its  bulk  and  weight,  and  when  it  suppurates  it  suppurates  mild- 
lv  :  but  wherever  any  part  ot  the  body,  except  the  cellular  fat 
or  muscular  flesh  is  engaged  in  the  disease,  wherever  the  eye, 
the  breast,  the  testicle,  a  bone  or  a  joint ;  wherever,  in  short,  any 
part,  having  a  complicated  structure,  is  affected,  however  long  it 
may  have  held  the  character  of  a  mere  overgrowth  or  simple 
tumour,  it  is  ever  to  be  feared,  that  sooner  or  later,  its  structure 
will  undergo  unfavourable  changes,  Irom  long  distention,  from 
occasional  excitement,  lrom  blows  or  other  injuries,  and  from 
changes  seemingly  internal  and  spontaneous  ;  or,  in  other  words, 
from  physical  causes  which  our  patient  has  not  remarked,  and 
which  we  cannot  trace.  Thence  results  another  rule  equally 
established  in  my  mind,  that  no  tumour  of  a  doubtful  nature 
should  be  permitted  to  grow,  even  through  that  period  in  which 
it  seems  indolent  ;  for  when  it  inflames  or  compresses  the  sur- 
rounding parts,  when  it  is  likely  to  suffocate  our  patient,  or  to 
end  in  a  malignant  and  fetid  sore,  it  is  so  fixed  as  to  defy  all 
surgery. 

I  have  perhaps  reason  to  suspect  the  opinion  I  have  concei- 
ved of  the  importance  of  a  subject,  which,  from  long  contem- 
plating it  in  its  various  relations,  has  made  an  impression  on 
my  mind  which  gains  strength  while  I  endeavour  to  infuse  it 
into  yours ;  to  an  author,  his  favourite  theme,  his  present 
theme,  seems  ever  important.  The  surgeon,  no"  doubt,  when 
he  proclaims  the  importance  of  a  favourite  subject,  is  bound  in 
a  peculiar  manner  to  prove  it  in  detail, — to  prove  it  by  facts  : 
yet  I  know  not  why  he  should  be  debarred  the  common  privi- 
lege of  explaining  without  a  pointed  reference  to  facts,  whence 
the  general  impressions  he  has  received  have  taken  their  rise:  he 
most  of  all  may  be  pardoned  an  overweening  love  of  his  pro- 
fession, who  sees  it  daily  a  source  ot  relief  Irom  pain,  from  clan- 
ger, and  from  death  inevitable,  but  for  his  interposition  :  he 
may  be  acquitted  of  any  affectation  of  extraordinarv  sympathy 
and  feeling,  who  has  been  called  at  all  hours  and  scasous,  from 


376  Of  the  parts  most  subject  to  Tumours. 

his  bed,  his  table,  his  family,  to  witness  the  agonies  of  a  friend 
suffocating  from  the  bulk  of  a  tumour, — alarmed  with  haemorr- 
hagies  which  threaten  life,  or  wasting  under  the  cruel  pains  of 
cancer.  Can  the  surgeon  be  accused  of  affected  sensibility, 
who  describes  with  interest  scenes  in  which  he  has  so  great  a 
share,  so  far  different  from  that  even  of  the  nearest  friend,  so 
much  the  more  responsible  ?  He  alone  sees  all  the  variety  of 
misery,  the  least  part  of  which,  if  witnessed  by  common  spec- 
tators, is  related  in  affecting  terms  ;  he  alone  knows  the  trivial 
beginnings  and  sad  conclusions  of  diseases,  and  can  form  a  true 
estimate  of  their  importance.  The  surgeon,  in  representing 
the  interest  which  particular  diseases  should  excite,  deals  not  in 
the  fantastic  horrors  which  the  moralist  conjures  up  when  he 
declaims  against  the  vices  of  a  declining  age,  or  the  politician, 
when  the  iniquity  of  public  measures  is  his  theme,  and  he  pre- 
dicts the  ruin  of  his  country  :  the  surgeon's  mind  is  occupied 
with  distinct,  impressive  recollections  of  what  individuals  have 
suffered  ;  though  steeped  in  the  colour  of  his  trade,  inured  to 
blood,  he  may  be  allowed  to  feel  every  degree  of  sympathy  with 
scenes  of  distress,  presented  to  his  imagination  in  such  various 
and  afflicting  forms. 

Believe  me,  Gentlemen,  I  use  no  art  to  engage  you  in  this 
department  of  study,  and  do  not  seek  by  exaggeration  to  en- 
hance its  importance  :  what  I  think  and  feel,  I  must,  in  justice 
to  you,  speak  freely,  and  without  restraint ;  and  surely  no  way 
can  be  so  faultless  as  to  lay  before  you  a  slight  and  preliminary 
sketch  of  the  various  parts  subject  to  tumours,  and  the  various 
consequences  of  their  growth,  as  they  affect  the  skin,  the 
glands,  the  bones,  the  eye,  the  breast,  the  testicle,  the  throat, 
the  rectum,  or  other  hollow  passages  of  the  body,  ruining  by 
pressure  and  ulceration,  the  structure  of  the  affected,  and  the 
adjacent  parts. 


SECTION   II. 

Of  the  parts  most  subject  to  Tumours. 

The  Skin  is  the  part  of  the  body  perhaps  the  most  vascular 
and  delicate,  and  is  often  by  injuries,  as  by  the  pulling  off  the 
hair,  or  the  pinching  or  bruising  of  its  vessels  so  excited,  that 
its  vessels  taking  on  a  lively  action,  its  arteries  and  veins  are  in 
process  of  time  dilated,  and  form  aneurisms,  or  bleeding  tu- 
mours ;  or  they  are  merely  by  such  excitement  so  quickened  in 
their  ordinary  function  of  nutrition,  that  the  whole  web  of  in- 


Of  the  parts  ynost  subject  to  Tumours.  %T7 

teguments  becomes  a  tumour,  retains  its  natural  form  and  sub- 
stance, with  only  some  slight  enlargement  of  its  pores  and  pa- 
pillje,  but  becomes  so  voluminous  as  to  be  wrapped  round  the 
body,  forming  thus  the  most  extraordinary  tumuurs,  which  are 
still  nothing  but  skin. 

The  Bones,  as  vascular  as  the  softer  parts,  and  perhaps  more 
regularly  and  unceasingly  absorbed  and  replaced,  form,  when 
they  are  injured,  the  most  bulky,  and,  lrom  their  solid  texture, 
the  most  permanent  tumours,  which,  when  they  turn  to  ulcera- 
tion and  caries,  are  the  most  incurable  and  fatal.  We  very  fre- 
quently observe  a  tumour  of  a  bone  to  follow  a  blow,  and,  when 
the  blow  and  the  swelling  take  place  near  a  joint,  when  the  knee, 
the  wrist,  the  shoulder,  or  the  ankle  are  involved  in  the  tumour, 
its  growth  is  extremely  rapid.*-  Often  I  have  seen  the  radius,  when 
the  wrist  has  been  fractured  and  ill  re-united,  form  an  enor- 
mous bony  tumour  ;  or  the  heads  of  the  tibia  and  fibula  swell 
out  in  consequence  of  a  bruise  into  a  tumour  cavernous  and 
gristlv,  partly  occupied  with  matter  and  partly  formed  of  a  solid 
in. rease  of  bone,  till  the  thigh  almost  equalled  the  body  in 
thickness.  Very  often  such  tumours  bursting  pour  out  the 
most  fetid  matter  ;  and  large  bony  cavities,  or  numerous  honey- 
comb-like cells  are  formed.  Olten  too  without  external  vio- 
lence, without  any  conspicuous  marks  of  a  scrophulous  habit, 
without  any  possible  relation  to  venereal  diseases  ;  the  bones 
universally  are  disposed  to  form  tumours,  bv  which  sometimes 
the  hands  are  delormed,  the  wrists  swelled,  the  fingers  crooked 
like  birds'  talons,  and  sometimes  the  long  bones,  as  the  thigh- 
bones, shoulder-bones,  ribs  or  scapulas,  are  studded  with  large 
knobs  or  grow  out  in  tumours.  These  are  diseases  still  more 
dismal,  quite  irremediable. 

The  Glands,  when  their  vessels  are  excited  by  blows,  by 
cold,  by  the  absorption  of  foul  and  virulent  matter,  are  enlarged 
beyond  all  credible  limits,  and  draw  the  adjacent  parts  into  dis- 
ease, insomuch  that  the  tumour  which  originally  was  a  simple 
gland  has,  in  the  end,  a  very  anomalous  aspect,  and  conveys 
such  confused  impressions  to  the  feel,  that  we  know  not  how  to 
pronounce  upon  its  nature,  which  the  history  only  of  the  tumour 
can  in  any  degree  elucidate.  These  are  the  tumours  which, 
when  seated  either  within  the  mouth,  or  at  the  angle  of  the  jaw, 
repress  the  tongue,  displace  the  trachea,  or  obstruct  the  free  pas- 
sage of  the  food  and  air,  and  connect  ih>  mselves  so  with  the 
branches  of  the  carotid  arteries,  that  the  hand  of  the  most  in- 
trepid surgeon  can  no  longer  avail,  and  wise  and  prudent  men, 
met  in  consultation,  shrink  from  those  duties  which  the  patient's 
manifest  danger  plainly  imposts,  lest  t!  ey  should  bring,  not 
themselves  only,  but  their  prof*  ssion  into  disgrace. 

3  B 


378  Of  the  parts  most  subject  to  Tumours. 

The  Eye,  a  part  it  once  exquisitelv  sensible,  and  exquisitely 
vascular,  and  consisting  of  humours  which  arc  in  a  state  of  con- 
tinual circulation,   being  continually   secreted  and  re-absorbed, 
grows  by  the   slightest  excess  of  vascular  action  into  a  tumour. 
Sometimes  the  secretion  of  aqueous  humour,  not  changed,  but 
merely  augmented,  distends  the  globe  of  the  eye  into  a  tumour 
continually  increasing,  till  first  vision  is  deranged,  (not  destroy- 
ed) next  head-achs  ensue,   and,  finally,  the  coats   of  the  eye 
give  way.     On  other  occasions  the  adnata,  or  loose  and  vascular 
coat  of  the  eye,  arising  from  the  inner  surface  of  the  eyelids 
and  connecting  them  with  the  skin,  is  so  swelled  by  inflammation, 
that  its  cellular  substance  being  of  a  spongy  nature,  the  tumour 
of  it  covers  and  involves  the  whole  eye,  conceals  the   eye-ball, 
protrudes  far  beyond  the  eyelids  red,  flesh-like,  and  often  ulce- 
rated, so  as  to  seem  in  the  hasty  opinion  of  ignorant  surgeons 
a  cancer  of  the  eye :  even  for  such  a  disease,  so  little  connected 
with  the  globe  of  the  eye,  or  allied  with  cancer,  have   I  known 
the  whole  eye-ball  extirpated.       Sometimes  the  deeper  parts  of 
the  eye  are   so  inflamed  as  to  terminate  in  suppuration  of  the 
globe,  after  delirium  and  dreadful  pains  ;  then  the  central  parts 
having  suppurated,  the  firm  coats  of  the  eye  at  last  ulcerate,  the 
globe   bursts,   the  eye  subsides  into  its  socket,  and  the  eyelids 
close  upon  what  remains  of  its  coats:  but  these,  thickened  by 
continual  inflammation,  harden  and  grow  into  a  new  and  more 
formidable  tumour ;  and  the  eye  protrudes  again  from  its  sock- 
et, of  a  scirrhous  hardness,  with  a  painful  and  burning  ulcera- 
tion.      Sometimes  from  a  suppuration  less  deep  or  extensive, 
where  not  the  vitreous  humour  or  whole  body   of  the  eye,  but 
only  the  cornea  and  the  iris  are  diseased,  the  eye  becomes  can- 
cerous ;  for  when,  after  a  partial  suppuration  and  ulceration  of 
the  eye,  the  iris  very  often  throws  out  a  fungus,  bearing  the  true 
chaiacter  of  cancer,  even  from  the  first,  or  becoming  so  by  the 
excoriation  of  the  tears,'  and  the  friction  of  the  eyelids.      The 
lachrymal  gland  seated  within  the  socket  is  often,  as  T  shall  have 
occasion   to  explain  by  examples,  a  cause  of  incurable  disease, 
and   the   small  glands  or  lacunae  of  the  tarsus,  or  cartilaginous 
borders  of  the  eyelids,  form  tumours   extremely  firm  and  unal- 
terable in  their  nature,  sometimes  indeed  stationary,  but  never 
resolving  under  any  course  of  treatment,  and  often  causing  such 
pain  and  inflammation  of  the  eye  as  to  require  extirpation.     All 
the  parts,  in  short  of  this  delicate   organ,  whether  proper  or 
merely  adjacent,  are  subject  to  tumours  more  frequently  cancer- 
ous than  mild. 

The  Breast  is  a  gland  destined  to  perform  a  secretion  more 
profuse  nd  rapid,  in  proportion  to  its  size,  than  even  that  of  the 
salivary  glands,  and  more  elaborate.      It  is  subject  to  great  pe- 


Of  the  parts  most  subject  to  Tumours.  3T9 

riodical  excitements  j  at  each  menstrual  period  it  swells  slight- 
ly, is  greatly  enlarged  by  pregnancy  and  suckling,  and  in  warm 
climates,  or  diseased  constitutions,  in  all  countries,  it  is  the  part 
first  and  most  conspicuously  enlarged.  The  period  of  life  at 
which  menstruation  ceases  is  so  critical  for  this  gland,  that  it 
then  falls  into  scrophulous  and  cancerous  diseases,  having  every 
variety  of  aspect.  Sometimes  the  whole  breast  is  indurated 
and  enlarged,  with  a  swelling  so  truly  scrophulous,  that  I  have 
seen  the  breast  suppurate,  burst  out  like  other  scrophulous 
glands,  heal  at  one  point  and  ulcerate  in  another,  become  indu- 
rated to  an  extreme  degree-,  and  pour  out  from  various  openings 
a  limpid  serum  in  prolusion,  proportioned  to  the  natural  secre- 
tion of  the  gland.  Oiten  there  takes  place,  both  in  women  who 
give  milk  and  in  those  more  advanced  in  years,  a  voluminous 
abscess,  which  is  both  formed  so  slowly,  and  lies  involved  in  so 
thick  a  mass  of  indurated  gland,  and  so  void  of  pain,  that  it  is 
distinctlv  marked  as  a  scrophulous  disease.  In  both  the  iiffec- 
tions  of  the  mamma  here  described,  though  as  far  removed 
from  schirrus,  as  scrophulous  swelling  oi  the  testicle  from  can- 
cer of  that  part, -I  have  seen  the  breast  amputated  with  circum- 
stances of  particular  cruelty.  From  scrophulous  inflammation, 
blows,  milk-fever,  or,  in  consequence  of  that  indescribable 
change  which  take  place  at  tne  ceasing  of  menstruation,  the 
gland  of  the  breast  is  hardened,  either  in  one  mass  or  in  sepa- 
rate kernels,  which,  however  long  they  may  remain  indolent, 
become  sooner  or  later  inflamed,  and  then  the  proper  gland  of 
the  breast,  the  lymphatic  glands  connected  with  it,  the  skin,  and 
cellular  substance,  even  the  pectoral  muscle  itself,  are  apt  to  be 
massed  together  into  one  hard  globular  and  ponderous  tumour, 
with  separate  glandular  tumours  interspersed  in  the  surrounding 
cellular  substance.  When  this  mass  ulcerates,  the  axillurv 
glands,  previously  indurated,  also  inflame  ;  the  skin  of  the  axil- 
ia  reddens,  as  that  of  the  breast  ulcerates;  the  whole  armpit 
swells,  the  arm  becomes  (edematous,  and  lies  powerless  ;  and 
the  patient  dies  in  a  most  loathsome  state,  with  foul  and  very 
letid  matter  running  from  the  sore  in  great  prolusion,  so  as  to 
make  the  last  offices  ol  friends  difficult  to  periorm.  Sometinus 
this  disease  begins  like  a  kernel  in  the  centre  of  the  gland,  some- 
times like  an  excoriation  ot  the  nipple,  sometimes  like  a  mere 
contraction  and  induration  of  the  skin,  not  be  ginning  invariably 
round  the  nipple,  but  extending,as  I  have  several  times  remark- 
ed, from  the  axilla  downwards,  so  as  to  affect  the  bn  ast.  Thus 
a  careful  observer  sees  in  the  course/if  pra<  tice  a  sad  variety  of 
disease  in  this  part,  according  with  the  various  structure  of  those 
parts  in  which  the  disease  lv.  gins,  or  the  species  of  the  malady, 


380  Of  the  parts  most  subject  to  Tumours. 

whether  varicose,  scrophulous,  or  cancerous  ;  varieties  which, 
simple  as  the  part  seems  to  be,  are  as  widely  different  from  each 
other,  as  venereal,  scrophulous,  or  simple  inflammatory  affec- 
tions of  the  eye  are  from  one  another,  or  affections  of  the  cor- 
nea from  those  of  the  humours. 

The  Testicle  is  a  part  subject,  like  the  eye  and  breast,  to 
cancerous  affections,  often  commencing  in  venereal  inflamma- 
tion, affecting  the  structure  of  the  gland,  or  arising  irom  blows 
or  falls,  complicated  almost  always  with  a  watery  tumour  ol  the 
tunica  vaginalis,  and  indurations  of  the  spermatic  chord.  These 
diseases,  too  often  concealed  even  from  the  surgeon,  arrive  at 
their  last  stage  undivulged  :  but  the  scene  is  dreadful  indeed 
wh<  n  either  before  operation  the  testicle  bursts  out  into  open 
ulcer,  or,  alter  an  operation  performed  too  late,  the  chord,  be- 
ing diseased,  protrudes  from  the  upper  angle  of  the  wound  in  the 
form  of  a  fungus  or  cauliflower-like  tumour,  which  it  is  in  vain 
to  extirpate  with  either  ligature  or  knife,  for  it  shoots  out  again 
in  a  day,  bleeds,  and  discharges  the  most  fetid  sanies,  accom- 
panied with  cruel  pains  of  which  the  patient  dies. 

The  Membranes  lining  the  Nostrils  are  of  so  vascular 
and  glandular  a  nature,  so  continually  exposed  to  the  air,  and 
yet  so  delicate  and  sensitive,  that  tumours  arise  even  from  the 
very  slightest  irritation.  These  tumours,  mild  perhaps  in  their 
own  nature,  are  dreadful  in  their  consequences,  from  being 
seated  in  narrow  passages,  limited  not  by  dilatable  membranes, 
but  by  unyielding  bones,  which  suffer  every  kind  of  disorder 
when  thr  passages  begin  to  be  filled  with  even  the  softest  of 
these  tumours,  while  the  cavities  of  the  antrum  highmorianum, 
and  other  cells  far  out  of  the  reach  of  instruments,  are  often  oc- 
cupied by  tumours  of  a  more  malignant  nature.  So  destructive 
are  the  consequences  of  even  the  mildest  tumour,  growing  and 
distending  these  passages,  that  we  know  not  how  to  admit  or 
refuse  that  definition  of  tumour  so  often  mentioned  in  books, 
rt  The  Cancerous  Polypus;  for  no  cancer  can  be  more  des- 
tructive than  even  the  most  simple  polypus.  Little  does  the  patient 
apprehend  the  fate  that  awaits  him,  when  a  small  tumour  which 
he  can  just  touch  with  the  point  of  the  finger,  soft,  pendulous, 
void  of  pain,  and  attended  with  no  worse  disorder  than  sneez- 
ing and  watering  of  the  eyes,  first  appears  :  it  is  not  that  slight 
sense  of  suffocation  which  first  alarms  him,  increasing  to  a  to- 
tal obstruction,  that  occasions  his  death  ;  but  the  narrowness  and 
crookedness  of  the  passages  of  the  nostrils  and  throat,  and  the 
vicinity  of  those  parts  to  the  brain,  separated  indeed  only,  by 
the  thin  plate  of  the  ethmoid  bone  that  occasions  death.  The 
bones  first  become  soft  and  carious,  and  discharge  a  fetid  and 
acrid  matter,  which  distils  in  such  profusion  as  to  excoriate  the 


Of  the  parts  most  subject  to  Tumours.  381 

lip,  and  to  cause  diarrhoea  by  running  down  the  nostrils  and 
throat.  The  blood  bursts  impetuously  from  the  corroded  ves- 
sels from  time  to  time :  the  hearing  is  entirely  interrupted  by 
the  pressure  of  the  tumour  on  the  mouths  of  the  Eustachian 
tubes:  the  teeth  fall  out  Irom  the  socktts,  in  const  quence  of 
the  caries  of  the  alveolar  processes  :  the  head  seems  rending 
asunder  with  distracting  and  continual  pains  :  usually  the  patitnt 
is  exhausted  by  long  suffering,  and  Irtqutnt  loss  of  blood; 
sometimes  he  lives  till  cartes  ot  the  ethmoid  bone  admits  the  ul- 
ceration to  the  brain,  and  he  dies  lethargic. 

The  Gums,  when  they  fall  into  a  diseased  condition,  hard 
as  they  are,  (and  their  hardness  approaches  more  nearly  to  the 
consistence  ol  the  teeth  and  jaw-bones,  which  the\  connect  to- 
gether, than  to  that  ol  flesh,)  throw  out  tumours  so  luxuriant, 
so  truly  fungous,  so  profusely  supplied  with  blood,  that  the  hae- 
morrhagies  from  them  are,  even  irom  the  first,  alarming,  and 
are  in  the  end  fatal  ;  and  the  tumours,  when  extirpated  with  the 
scalpel,  or  torn  auav  with  ruder  instruments,  olten  sprout  up, 
(alter  the  very  bones  have  been  laid  naked,)  in  the  spate  of 
twentv-four  hours,  and  effloresce  in  the  course  of  a  ft  w  da\s 
into  cauliflower-like  excrescences,  and  still  grow  so  rapidly,  ac- 
companied with  dislocation  ol  the  teeth  and  carus  of  the  jaw, 
that  the  patient  expires  of  haemorrhagy,  diarrhoea,  and  cance- 
rous pain.  There  is  no  form  of  tumour  I  so  greatly  dread,  none 
so  rapid  in  its  growth,  as  those  proceeding  from  these  callous 
gums,  nor  any  disease  in  consequence  of  which  I  have  suffered 
sueh  severe,  unlooked-for  disappointments,  or  seen  such  unsuc- 
cessful operations  and  horrible  deaths.  Sometimes  the  extirpa- 
tion is  successful,  and,  I  think,  I  can  often  predict  w  hen  it  will 
be  so  ;  but,  when  it  fails,  no  cauterizing,  nor  the  most  cruel  pro- 
cesses of  surgery,  will  repress  the  alter  growth  ;  it  is  truly  can- 
cerous, and  invariably  fatal. 

Tumours  of  the  Throat,  whether  external  to  the  jaws,  or 
visible  only  within,  give  no  alarm  but  by  the  efltct  the)  [%oduce 
on  the  breathing  and  swallowing  ;  and  yet  they  are,  beyond  all 
comparison,  the  most  dangerous  tumours,  fatal  if  neglected,  and 
yet  so  connected  with  great  vessels  and  nerves,  that  to  extirpate 
them  is  almost  impracticable. 

Suppurations  within  the  throat  of  a  scrophulous  nature  are 
frequent;  and  I  shall  have  occasion  to  lay  before  you  examples 
of  these  bursting  by  multiplied  openings  into  the  lar\  nx  and 
oesophagus  occasioning  suffocation  by  the  matter  falling  into  the 
trachea,  or  inanition  and  death  by  the  contraction  of  the  oesopha- 
gus, in  consequence  of  long  ulceration.  Other  tumours  again, 
which,  at  first  sight,  the  surgeon  is  disposed  to  imagine  are  sacs 
of  purulent  or  serous  matter,  and  which   I  confess  myself  to 


-382  Of  the  parts  moat  subject  to  Tumours. 

have  mistaken  for  such,  are  sacs  of  blood  formed  by  dilatation 
of  the  extreme  arteries  and  veins ; — aneurisms  of  that  kind, 
which  I  have  formerly  described  under  the  name  of  aneurisms 
by  anastomosis,  but  lying  too  deep  under  the  skin  and  the  pla- 
tysma  myoides  muscle,  and  too  near  to  the  great  carotid  arte- 
ries and  its  accompanying  nerves,  to  admit  of  extirpation. 
Sometimes  I  have  found  tumours,  especially  occupying  the  fore- 
part of  the  neck,  in  the  place  of  the  thyroid  gland,  to  be  sacs  of 
blood,  but  of  a  structure  widely  different  from  that  of  those  an- 
eurisms, and  perfectly  curable,  distinguishable  from  those  ca- 
ses of  aneurism  by  anastomosis,  in  having  no  pulsation,  and  a 
thicker  sac.  The  tumour  is  stationary  in  respect  of  size,  and 
not  becoming  more  turgid  upon  retaining  the  breath,  nor  flatter 
when  the  blood  is  repressed  by  the  hand :  there  is  no  conge- 
ries of  active  vessels  opening  into  them,  and  supplying  them 
with  blood.  The  blood,  I  find,  has  all  the  characters  of  having 
remained  long  in  the  sac,  and  the  sac  itself  is  of  a  firm,  consis- 
tence, difficultly  brought  to  suppuration,  infinitely  more  diffi- 
cult to  obliterate  than  those  sacs  which  contain  matter  or  serum, 
and  leavit.g  behind  them  a  permanent  thicking  of  the  throat. 
Aneurisms  of  the  carotid  arteries  are  not  frequent,  but  I  have 
seen  a  pure  and  simple  dilatation  of  this  vessel  under  the  angle 
of  the  jaw,  of  the  size  of  a  fist,  intruding  upon  the  throat  rather 
than  projecting  outwards,  little  conspicuous  as  a  tumour,  but 
having  an  awful  throbbing  pulse,  when  the  palm  of  the  hand 
was  laid  over  it.  One  would  fear  nothing  in  such  aneurism 
but  the  bursting,  and  the  loss  of  life  by  hsmorrhagy;  but  long 
before  the  sac  inflames  or  ulcerates,  the  fever  with  which  it  is 
accompanied,  and  the  difficulty  of  swallowing,  arising  simply 
from  its  pressure  upon  the  pharynx,  occasion  death.* 

The  Salivary  and  Lymphatic  Glands,  lying  under  the 
tongue,  and  about  the  angles  of  the  jaw,  are  frequently  diseased, 
and  form  tumours  varying  greatly  in  their  form  and  nature, 
and  growing  sometimes  to  an  enormous  size ;  usually  they  con- 
tain a  gelatinous  matter,  thick,  ropy,  sacculated,  and  mixed 
with  solid  bodies  like  grains  of  millet  or  mustard-seed,  some- 
times a  pultaceous  matter:  often  these  tumours  are  so  far  fluid, 
as  to  give  hopes  when  first  the  sac  is  opened,  that  the  tumour 
will  entirely  subside, and  the  sac  be  easily  obliterated;  but  so 
far  solid  as  to  mock  these  expectations,  for,  while  the  matter 
runs  out,  the  base  is  indurated,  so  that  before  the  opening  of 
the  sac  is  closed,  the  base  has  become  a  tumour,  firm,  glandu- 
lar, and  visibly  increasing.  Sometimes  these  glandular  tumours 
especially  such  as  are  seated  under  the  jaws,  though  of  a  stony 
hardness,  are    moveable,   subject  to  no  pain  nor  occasional  in- 

*  The  carotid  artery  has  been  fuccefsfully  tied  by  Mr.  Aftlcy  Cooper  when  af- 
fected with  aneurism.     S. 


Of  the  Tumours  of  the  Bones.  383 

flammation,  not  adhering  to  the  skin  nor  subjacent  parts,  bat 
indolent  and  harmless.  Always  in  children  and  bo}s,  some- 
times too  in  adults,  such  indurated  glands  are  harmless,  but  of 
firm  and  knobulatcd  tumours,  especially  of  those  seated  in  the 
cheek,  covered  with  a  coarse,  porous,  and  puckered  skin,  and 
connecting  themselves  strongly  with  the  surrounding  parts,  livid 
on  their  more  promintnt  points,  and  aching  with  every  change 
of  weather  or  season,  I  have  never  seen  a  happy  issue.  There 
is  no  safety  for  the  patient  who  is  endangered  by  such  a  tumour, 
except  in  extirpation ;  nor  can  we  assure  him  that  such  an  ope- 
ration (not  always  void  of  danger,)  will  eradicate  the  disease. 

These  preliminary  sketches  and  characters  of  tumours,  shall 
serve  as  a  slight  index  of  the  subjects  I  have  to  explain  in  de- 
tail: the  varieties  of  suffering  will  be  but  too  truly  confirmed  by 
facts  :  the  distress  the  patient  suffers  who  dies  of  any  form  of  tu- 
mour, whether  suffocating,  carious,  or  cancerous,  exceeds  what- 
ever the  most  eloquent  writer  on  professional  subjects  could 
represent,  or  the  warmest  imagination  conceive.  Believe  me, 
it  is  the  sufferings  of  individuals  that  have  given  me  such  deep 
impressions,  and  you  shall  feel,  before  I  have  finished  the  nar- 
ratives of  the  cases  corresponding  with  these  characters,  how 
little  I  am  inclined,  how  little  I  need  to  exaggerate,  the  impor- 
tance of  this  subject. 


DISCOURSE  XXI. 


OF  TUMOURS  OF  THE  BONES. 

lNT  this  discourse,  which  is  devoted  to  the  diseases  of  the  bones, 
I  shall  first  sketch  out  to  you  mv  conctption  of  those  changes 
which  happen  in  the  structure  of  bone,  before  it  swePs  into  a 
tumour ;  and  shall  next  lay  before  you  the  facts  in  detail,  from 
which  those  conceptions,  true  or  false,  have  arisen. 

Every  tumour  must  derive  its  peculiar  fcrm  from  the  structure 
of  that  part  of  the  body  from  which  it  arises  ;  for  it  is  not  seated 
on  the  part  as  a  new  and  accidental  existence, but  is  engender?  I 
bv  its  vessels,  and  is  of  its  actual  substance.  Many  things 
conspire  to  give  the  tumour  proceeding  from  a  bone  a  peculiar 


384  Of  the  Tumours  of  the  Bones. 

aspect;  it  is  always  irregular  and  anomalous,  never  simple.  I 
have  rarely  seen  a  single  bony  protuberance  arising  Irom  the 
head  or  the  shaft  of  a  single  bone.  When  a  bone  tails  into  dis- 
ease, a  large  proportion  of  tendinous  and  muscular  parts,  ot 
bursae,  and  ot  cellular  subbtance,  partake  ot  the  morbid  action. 
The  bom  lies  in  the  centre  ot  the  limb  connected  by  its  larger 
head  with  the  joint,  and  by  its  periosteum  with  the  tendons, 
bursa?,  and  muscles  ;  and  all  this  mass  ot  parts  is  sooner  or  la- 
ter affected  ;  and  since  every  deposition  from  vessels  appointed 
for  the  secretion  ot  bone  is  solid,  and  every  increase  ot  such  a 
tumour  permanent,  it  soon  attains  a  great  size  ;  it  is  ponderous 
and  massive  from  the  proportion  of  bony  secretion,  and  from 
the  various  structure  of  these  several  parts,  it  has  every  irregu- 
larity of  form  and  substance. 

When  the  tumour  of  a  bone  has  attained  a  considerable  size, 
much  of  the  original  structure  is  destroyed,  and  a  new  irregu- 
lar mass  of  gelatinous  and  bom  matter  is  substituted  for  it.  The 
bony  tumour  is  firm,  bulky  and  ponderous,  but  not  solid  ;  feel- 
ing  it  from  without,  we  can  conjecture  of  what  substance  it  is 
composed  within  ;  we  are  sensiole  that  the  tumour  is  covered  by 
a  shell,  bony  in  most  part  of  its  circumference,  cartilaginous  in 
some  parts,  and  throughout  the  whole  yielding  and  elastic ;  we 
are  sensible  also,  that  within,  there  are  irregular  points  or 
spicule  traversing  the  cavities  or  cells  of  the  hollow  tumour ; 
that  these  are  mixed  with  the  cartilaginous  substance,  and  with 
irregular  collections  of  matter,  partly  purulent,  but  chiefly  ge- 
latinous ;  and  we  find  at  last,  by  pain  and  partial  ulcerations, 
and  by  the  increase  of  fluctuation  and  redness  at  particular  points, 
that  ulceration,  the  last  stage  of  the  disease,  approaches  ;  then 
the  limb  is  effectually  ruined,  and  the  patient  must  submit  to  am- 
putation, or  die  hectic. 

When  such  tumour  is  dissected,  we  find  our  suspicions  of  its 
internal  structure  confirmed  ;  we  see  that  foul  matter  flow  out, 
when  we  open  into  the  centre  of  the  tumour,  which  we  felt  but 
indistinctly  through  its  walls  ;  the  parts  of  which  appeared  the 
most  solid,  are  hollowed  out  bv  ulceration,  and  full  of  foul  and 
putrid  sanies  ;  while  the  bone  has  been  declining  into  disease, 
the  cancelii  and  marrow  have  been  degenerating  into  a  sort  of 
fatty  mass,  with  which  much  of  the  cavity  of  the  tumour  is  fil- 
led, and  thence  such  disease  has  been  very  generally  described 
under  the  name  osttot-teutoma.  This  fatty  secretion,  occupying 
the  diseased  cavity,  is  the  part,  which,  when  the  tumour  bursts 
into  open  ulcer,  throws  out  such  prolific  fungus,  growing  appa- 
rently from  the  substance  of  the  bone,  and  sprouting  up  when 
amputated,  in  the  course  of  a  few  hours.  The  solid  bone,  whe- 
ther radius  or  thigh-bone,  is  annihilated,  and  a   mere   shell  of 


Of  the  Tumours  of  the  Bones.  ♦  385 

osseous  matter  substituted  in  its  place,  and  that  in  a  manner  so 
peculiar,  that  it  must  seem  to  the  unintelligent  observer,  as  if 
the  small  and  solid  bone  had  been  expanded  into  an  extensive 
and  flat  plate  of  osseous  substance,  whereas  the  process  is  in 
truth  very  simple  and  very  intelligible.  The  bone  dies  piece- 
meal of  ulceration,  or  what,  in  technical  language  is  termed  ca- 
ries, and  is  conveyed  away  by  absorption  ;  but  the  bone  being 
dead,  the  surrounding  membranes,  viz.  the  periosteum  and 
tendinous  expansions,  which  once  formed  a  part  of  its  system 
of  circulation,  continue  still  alive,  and  ready  to  secrete  new 
bone  ;  and  thus  it  happens  that  while  a  carious  abscess  preserves 
a  large  cavity  full  of  foul  matter,  the  surrounding  membranes 
continue  secreting  bone,  which,  like  a  shell,  thin  and  expanded, 
covers  this  cavity,  and  forms  the  walls  of  the  tumour,  of  which 
some  part  is  composed  of  thin  expanded  bone,  resembling  a 
cranium,  some  of  cartilage,  some  of  thickened  membrane  ;  and 
this  shell  is  formed  in  proportion  as  the  original  fabric  of  the 
bone  is  destroyed. 

Bone  is  destroyed  by  this  internal  ulceration,  just  as  it  is  by 
open  caries,  piecemeal  ;  the  process  would  not  be  ulceration, 
if,  while  one  part  were  perishing  the  other  were  not  active  and 
secreting  new  matter  ;  so  vigorous  still  is  the  general  life  of  the 
bone,  that  while  the  internal  parts  are  thus  suffering,  while  one 
side  is  wasting  with  ulcer,  the  other  side  is  often  secreting  bone 
irregularly  and  profusely,  and  shooting  out  into  fantastic  forms 
among  the  membranes  and  surrounding  parts,  wheuce  the  cen- 
tre of  the  tumour  is  cavernous  and  cellular,  and  the  walls  often 
rough  with  spinous  and  projecting  points.  So  merely  local  is 
the  action  of  arteries  in  a  tumour,  whether  osseous  or  soft,  that 
one  side,  or  part,  or  bump  of  a  tumour,  grows  visibly,  and 
protrudes,  the  features  and  external  form  of  the  tumour,  gra- 
dually changing,  without  any  sensible  cause  ;  and  so  peculiar  is 
the  secretion  of  each  species  of  vascular  structure,  according  to 
the  original  destination  of  the  part,  that  in  one  part  of  a  tumour 
is  generated  bone,  in  another  gristle,  in  another  gelatinous  effu- 
sion ;  while  in  another  part,  the  vascular  action  is  violent  and 
destructive,  and  the  solid  bone,  marrow,  and  surrounding 
membranes,  are  all  resolved  into  a  foul  and  fetid  suppuration. 
From  the  periosteum  is  secreted  bone  ;  from  the  marrow,  this 
steatomatous  and  solid  fat,  with  which  much  of  the  tumour  is 
tilled  ;  to  the  tendinous  and  aponeurotic  parts  we  can  distinctly 
trace  the  cartilaginous  secretion  ;  and  the  gelatinous  effusions 
we  can  perceive,  even  during  life,  are  thicker  or  thinner  accord- 
ing to  the  degree  of  inflammation. 

These  are  the  external  characters,  and  internal  conditions  of 

3  C 


38b  Of  the  Tumours  of  the  Bones. 

a  tumour,  occupying  any  of  the  bones.     Such  tumour  arises 
often  Irom  a  bruise  or  lracture  ;  sometimes  from  a  less  obvious 
cause,   or  from  internal  disease.      The  radius,  for  example,  is 
fractured  at  the  wrist,  re-unites,  and  heals,  but  heals  clumsily  ; 
the  thickening  never  subsides,  the  pain  never  ceases,  and  though 
not   great,  is  greater  than   what   is  natural   to   a  fracture  ;  at 
length  a  sensible  tumour  arises  ; — at  first  it  is  firm,  but  in  pro- 
portion as   it  increases  in  size,  it  becomes  somewhat  soft   and 
eUstx  :  the  thin  plate  of  bone  of  which  it  is  composed  yielding 
to  the  distention  from  within — From  time  to  time  the  tumour 
changes  its  form,  still  increasing  in  bulk  ;  on  the  side  of  the  ra- 
dius it  is  firm   and  solid  ;  it  bends  and  yields  at  the  parts  most 
distant  lrom  it  ;   it  is  plainly  bon\  at  its  basis,  and  as  obviously 
cartilaginous  in  the  extreme  part  of  its  circle  ;  it  plainly  contains 
matter  in  tho  e  softer  parts,  where  it  yields  to  the  impression 
of  the  finger  :  cartilaginous  knobs  arise,  and  sometimes  are  red- 
dened   >n  i.ie  surface  ;  and  at  certain  points  the  fluctuation  is  of 
such  a  km  I  as  to  imply,  that  the  effusion  is  in  part  of  a  gelati- 
nous nature      Thus  the  tumour  grows  and  txttnds,  with  vari- 
ous irregularities  in  form    and  consistence  ;  it  overhangs  the 
dwindled  hand,  the  use  of  the  joint  is  lost,  and  the  patient,  who 
would  gladly  be  delivered  of  it  at  an  earlier  stage,  has  in  the 
end  no  choice  left ;  for  wrhen  once  it  bursts  into  carious  ulcera- 
tion it  nev  r  heals,  the   fetor  is  inconceivably  overcoming,  at- 
tended  wich  hectic.     You  are  also  to  remark,  that  when  such 
d  s-a-e  takes    place  in  the  hand  itself,  the  joints  of  each  of  the 
fingers  grow  out  into  tumours,  at  first  of  a  heart-like  form,  cor- 
responding with  the  articulations  ot  the  finger-bones  ;  but  in  pro- 
ctss  of  time,  thev  grow  to  globular,  irregular,  and  almost  trans- 
parent tumours,  still  firm,  or  at  least  of  a  cartilaginous  firm- 
ness.     The  who  e  hand  degenerates  into  a  deformed  mass,  dis- 
coloured, ulcerated,  and   ietid  ;  from  the  individual  knobs  of 
this  d  firmed  mass,  the  points  of  the  respective  fingers  project 
like  griffi  i's  claws,  with  crooked  nails  of  enormous  length. 

You  will  conceive,  I  trust,  from  these  general  descriptions, 
an  idea,  not  far  from  perfect,  oi  the  irregular  forms,  and  inter- 
nal disorder  accompanying  this  disease  :  vou  may  imagine  how 
ill  the  surgeon  is  qualified  tor  practice,  who  is  not  aware  of  these 
changes  in  the  internal  structure  ;  he  feels  fluctuation,  and  re- 
gardless of  the  history  of  the  tumour,  of  its  firmness,  or  of  its 
connection  with  a  bone,  plunges  his  abscess  lancet  into  it,  and 
it  pours  out,  if  he  strike  deep  enough,  a  profusion  of  thick  mat- 
ter ;  he  then  believes  that  it  will  heal,  but  it  will  never  heal.  Or, 
knowing  it  to  belong  to  the  bone,  he  imagines,  perhaps,  that  it  is 
a  firm  and  solid  tumour,  but  believes  that  the  tumour  is  move- 
able, because  the  radius  moves  along  with  it,  allowing  it  to 


Of  the  Tumours  of  the  Bona.  387 

turn;  he  projects  an  operation  for  cutting  off  this  tumour  of  the 
bone,  but,  after  a  slow  and  painful  dissection,  he  finds  it  not 
solid  but  cavernous,  and  lull  of  fatty  or  fetid  mattrr  ;  he  finds 
the  bone  to  which  he  imagined  the  tumour  attached,  entirely 
gone,  and  the  joint  to  which  that  bone  belonged  entirclv  open  ; 
he  finds  the  smooth  cartilaginous  heads  01  the  wrist-bones  ex- 
posed in  the  cavity  of  the  ulcer;  and  is  forced,  after  the  patient 
has  lost  much  blood,  and  manfully  endured  a  slow  excruciating 
operation,  to  cut  off  the  hand.  Such  are  the  lesaons  which  x- 
perience  teaches,  and  I  have  known  instances  where  the  case 
and  all  its  probabilities  have  been  maturely  considered,  b\  men 
of  great  skill  and  judgment ;  where  a  Lynn,  surrounded  by  his 
approved  and  skiliul  friends,  has  reckoned  the  probability  of 
success,  such  as  to  vindicate  an  operation  ;  the  tumour  small, 
firmly  attached  to  the  radius,  turning  easil\  along  with  it,  not 
yet  distorting  the  tendons,  not  \et  intf  rrupting  the  use  ot  tne 
hand,  I  have  known  the  operation,  performed  even  bv  such  an 
operator,  fail.  Now,  in  such  cases,  the  tumour  does  not  cr  i-e 
to  grow,  the  incisio.is  heal  up,  the  part  ot  the  radius  cutout  by 
saws  grows  again,  the  tumour  continues  to  increase,  till  it  de- 
stroys the  wrist,  the  hand  dwindles,  the  fingers  grow  long, 
sh -ipeless,  and  powerless,  Irom  want  of  use,  and  amputation  is, 
in  the  end,  the  only  resource. 

The  forms  of  this  disgusting  disease,  which  never  fails  to  de- 
stroy the  l.mb,  are  infinitely  various.  I  have  setn  the  ankle  of 
a  woman,  from  a  very  slight  accident,  fall  into  this  disease  ;  the 
tibia  and  fibula  grew  into  a  common  tumour ;  the  bones  seemed 
to  me  annihilated,  and  a  large  shell  of  bone  substituted  in  their 
place.  The  leg,  in  the  course  of  the  disease,  twisted  round  in 
a  singular  manner,  and  the  limb  enlarged  to  the  size  ot  the  pil- 
low ot  a  settee.  Thia  woman  died  of  hectic,  from  ihe  open  ca- 
ries of  the  tumour.  The  wrist,  more  exposed  than  anv  other 
part  to  sprains  and  fractures  is,  very  liable  to  be  thus  de- 
formed and  ruined;  but  the  hand  itself  is  still  more  liable,  the 
original  injury  is  some  slight  blow  or  sprain ;— one  fing  r  is 
first  deformed,  joint  after  joint  enlarges,  one  fing:  r  becomes 
crooked  after  another,  the  nails  project  unpaired  like:  talons,  and 
force  their  wav  into  the  very  flesh  of  thr  swelled  and  ulcerated 
hand,  which  they  sometimes  actually  penetrate  through  and 
through;  the  hand  degenerates  into  an  unwieldy  and  irreg^  r 
mass,  studded  with  knobs  and  bony  tumours.  From  a  ne- 
glected fracture  of  the  collar-bone,  I  saw  once  in  a  stout  young 
roan,  (who,  living  a  most  dissolute  life,  kit  the  tracturc-d  part 
no  rest  to  heal  and  unite,)  a  tumour  formed,  partly  bony,  partly 
cartilaginous,  rising  to  the  height  ol  and.  iiis 

ted,  moving  when  the  arm  wa>  moved,  too  large  and  too  cnti- 


388  Of  the  Tumours  of  the  Bones. 

cally  seated  over  the  axillarv  artery,  to  admit  of  extirpation, 
and  which,  I  doubt  not,  has  by  this  time  become  carious,  and 
occasioned  his  death. 

The  stage  and  period  of  growth  at  which  such  a  tumour  may- 
be extirpated,  if  ever  such  operation  be  practicable,  I  profess 
not  to  know :  the  circumstances  must  be  very  favourable  in- 
deed, to  incline  me  to  undertake  such  an  achievement ;  it  is 
often  indeed  a  matter  of  doubt,  whether  it  would  be  advisable 
even  to  amputate  the  diseased  limb,  for  occasionally  we  see 
both  hands  thus  diseased,  and  often  the  tendency  to  form  such 
tumours  seems  to  prevail  through  all  the  osseous  system.  If 
the  disease  proceed  from  a  fracture  or  bruise,  we  cannot  ven- 
ture to  extirpate  the  tumour,  for  the  joint  is  diseased,  and  we 
have  no  resource  but  amputation :  if  the  tumour  is  spontaneous, 
and  without  any  violence  or  manifest  cause,  we  have  reason  to 
fear  it  is  a  constitutional,  and  not  a  local  disease  ;  and  dare  not 
propose  amputation  with  confidence  ;  it  is  only  in  the  rare  oc- 
currence of  a  bony  tumour  being  altogether  limited  in  its 
growth,  insulated  in  its  form,  solid  and  firm,  and  unaccompa- 
nied with  disease  of  the  surrounding  parts  ;  seated  on  the  shaft 
of  the  bone,  not  connected  with  the  joint,  and  yet  growing  to  a 
great  size,  and  threatening  destruction,  that  we  should  think  of 
any  such  operation.  Such,  perhaps,  is  a  case  recorded  by 
Heister,  of  a  great  bony  tumour  rising  from  the  middle  of  the 
sternum,  equal  in  size  to  a  child's  head,  which  was  successfully 
extirpated. 

The  general  description  of  this  disease,  and  the  chief  practi- 
cal lessons,  will  be  as  fully  illustrated  by  the  following  case,  as 
by  a  hundred  such,  for  it  includes  all  the  principal  features  of 
the  disease,  and  all  the  practical  difficulties,  which  the  surgeon 
may  have  to  encounter. 

"  A  labouring  man,  about  40  years  of  age,  sallow,  lean,  and 
meagre,  presented  himself  with  a  tumour  of  an  enormous  size, 
and  of  an  anomalous  character,  partly  solid,'partly  cartilaginous, 
occupying  two  thirds  of  the  fore  arm,  from  the  wrist  upwards  : 
the  hand  was  sound,  and  all  its  joints  limber,  the  wrist  bended, 
and  the  fingers  moved  easily  ;  it  was  from  pain  only,  and 
weakness,  and  the  incumbrance  of  so  great  a  tumour,  that  he 
could  no  longer  work  :  the  tumour  seemed  also  to  move  freely, 
whence  it  seemed  possible  to  dissect  it  away,  and  save  the  joint ; 
and  the  surgeon,  a  man  whom  I  respect  as  a  man  of  learning, 
skill,  and  consummate  prudence,  was  induced  to  begin  a  par- 
tial operation,  a  dissection  of  the  tumour,  from  a  sincere  desire 
to  preserve  the  right  hand  of  a  poor  labourer. 

"  But  here  you  are  to  take  notice,  (and  I  should  put  no  value 
on  a  case  which  did  not  convey  some  practical  lesson)  how  un- 


Of  the  Tumours  of  the  Bones.  389 

expectedly  we  are  sometimes  involved  in  great  perplexities  from 
reflecting  too  slightly  on  the  nature  of  a  tumour:  a  tumour  of 
this  singular  complexion,  any  tumour  indeed  which  requires  an 
operation,  should  be  so  particularly  examined,  as  to  enable  the 
surgeon  to  prognosticate  every  thing  that  could  occur,  and  to 
describe  the  disease  before  amputation,  as  precisely  as  if  it  lay 
already  dissected  before  him:  much  of  what  will  be  found  on 
dissection  mav,  in  almost  every  case,  be  anticipated,  and  every 
such  anticipation  will  be  happy  for  the  patient,  and  creditable 
for  the  surgeon.  The  surgeon  should,  at  least,  ascertain  the 
generalcharacter  of  the  tumour,  yet,  1  question  whether,  in  this 
case,  it  was  absolutely  known,  that  the  tumour  was  at  all  attach- 
ed to  the  bone  ;  that  it  was  merely  a  tumour  of  the  radius,  as- 
suredly not. 

"Little  is  to  be  learnt,  even  after  much  inquiry,  from  those 
of  the  lower  orders  concerning  the  early  stages  of  their  diseases. 
This,  perhaps,  was  of  a  nature  originally  malignant,  but  cer- 
tainly irritated  by  neglect  at  first,  and,  in  the  end,  by  imprudent 
advice  and  rash  applications  :  the  man  had,  about  six  or  eight 
months  before  applying  for  assistance,  first  observed  the  disease, 
in  the  form  of  a  circumscribed  swelling,  rising  upon  his  wrist, 
gradually  increasing,  and  becoming  daily  more  painful:  he  ima- 
gined it  right  to  apply  poultices,  and,  aiter  some  time,  brought 
it  happily,  as  he  imagined  to  a  suppuration :  but,  as  it  did  not 
heal,  a  mischievous  old  woman  undertook  the  cure,  cramming 
it  with  tents,  and  acrid  and  corrosive  powders,  and  making  so 
very  free  with  the  lancet,  that  he  narrowly  escaped  dving  of  a 
ruemorrhagy,  caused  probably  by  the  erosion,  or  wounding  of 
one  of  the  veins  above  the  wrist.  The  tumour  was,  at  the  time 
of  the  operation,  enormously  large  ;  it  was  at  the  lower  and 
bigger  part  of  a  dusky  brown,  but  at  its  upper  and  smaller  end 
of  a  fresher  colour,  with  a  wide  and  open  ulcer,  bleeding  at 
times,  and  disposed  to  throw  out  a  luxuriant  fungus,  to  suppress 
the  growth  of  which  was,  perhaps,  part  of  the  old  woman's  in- 
tention, in  applying  the  escharotics,  if  intention  of  any  kind  can 
be  imputed  to  so  ignorant  a  creature.  The  veins,  as  is  usual 
in  bony  tumours,  were  far  from  being  conspicuous  even  in  this 
part. 

"This  poor  man,  having  willingly  assented  to  any  operation, 
however  lingering  or  painful,  which  might  save  his  hand,  the 
dissection  was  carried  all  round  the  tumour  and  into  its  central 
parts,  before  the  surgeons  present  were  undeceived.  As  the 
radius  turns  vertically  like  a  spoke  or  spindle,  it  turns  without 
any  apparent  motion,  except  in  the  parts  connected  with  its  low> 
er  end ;  the  hand  turns  freely  along  with  the  radius,  so  that  we 
never  suspect  till  we  become  acquainted  with  ar.a'oniy,  that   it 


390  Of  the   Tumours  of  the  Bones. 

is  by  the  spoke-like  motions  of  the  radius  that  the  hand  moves ; 
it  seems  moveable  in  itself  by  its  own  immediate  joints.  This 
tumour,  in  like  manner,  moved  easily,  could  be  turned  upwards 
and  downwards,  so  that  the  surgeon  never  onct  suspected  that 
the  motion  was  in  the  radius,  or  that  the  tumour  was  fixed,  and 
made  a  part  of  that  bone  ;  it  seemed  moveable,  and  he  began  to 
extirpate  it,  by  drawing  a  long  incision  round  its  root,  on  the 
side  of  the  ulna  :  but,  finding  it  difficult,  with  this  limited  in- 
cision, to  dissect  the  tumour,  he  prolonged  the  incision,  con- 
tinuing it  over  the  back  of  the  hand  to  the  knuckles,  in  the  di- 
rection ol  the  t  xtensor  tendons.  He  then  dissected  more  free- 
ly, and  continued  separating  the  skin  from  the  tumour,  till  he 
came  to  a  thick  and  solid  sac,  which  seemed  to  consist  of  mus- 
cular and  ligamentous  fibres. 

M  He  continued  this  dissection,  separating  this  thick  and  solid 
sac  from  the   interosseous  ligament,  till  he  could  go  no  farther; 
finding  that  it  terminated  then  in  a  solid  and  osseous  basis,  he 
now  plunged  intrepidly  into  the  heart  of  the  tumour.     In  doing 
this  he  found  that  he  had  opened  a  very  large  sac,  not  firm  only, 
but  osseous  ;    but  still  as  he  was  penetrating  into  the  tumour  at 
one  side,  viz.   at   the   side  nearer  the  uina,  with  which  the  tu- 
mour was  manifestly  unconnected,  and  at  the  greatest  possible 
distance  from  the  radius,  from  which  the  tumour  in  fact  arose, 
he  continued   still   unsuspicious,  and   persevered  in  dissecting 
away  what  he  imagined  to  be  a  common  tendinous  sac,  ossified 
only  at  certain  points :  he   made  thus  a  large  opening  into  the 
tumour,  felt  its  cavity  full  of  loose  and  fatty  bodies,  pushed  his 
finger  under  the  extensor  tendons  into  the  deepest  part  of  the 
sac,  began  to  hook  out  the  fatty  tubercK  s  with  his   fingers,  and, 
at  last,  baling  it  out  with  his   hand,  (for   the   cavity  was  large 
enough  to  admit  his  hand)  hooking  with  his  finger  and  catching 
the  fatty  masses  in  his  palm,  he  so  far  emptied  the  cavity  as  to 
be  able  to  search  with  his  fingers  in  everv  direction,  and  then  he 
found,  to  his  utter  confusion,  the  ball  of  the  carpus,  (formed  by 
the  scaphoid  and  lunated   bones)  at   the  bottom  of  the  cavity, 
bare  :  he  was  now  for  the  first  time,  undeceived,  and  knew  what 
sort  of  disease  he  had  to  contend  with;  he  was  now  conscious, 
that  the  radius  was  diseased,  the  joint  ruined,  the  original  bone 
ulcerated  and  destroved  ;  he  felt  distinctly  that  the  ball  of  the 
carpal  bones,  originally  opposed  to  the  lower  end  of  the  radius, 
was  now,  by  the  destruction  of  the  radius,  left  naked  ;  and,  iu 
fine,  that  the  wrist-joint  was  irrecoverably  ruined.     There  was 
no  going  on  with  this  operation,  and  no  stopping  here  ;  he  there- 
fore explained  to  the  patient,   who  had  borne  this  severe  and 
long  oiotracted  dissection  with  great   composure,  the  necessity 
of  amputating  his  hand,  which  he  submitted   to   with    equal 
resignation." 


Of  the  Tumours  of  the  Bones.  391 

The  reflections  naturally  arising  out  of  this  case  are  obvious 
and  imprssive  ;  we  must  be  conscious  how  suduYnlv  a  surgeon 
may,  in  a  moment  of  thoughtless  security,  be  plunged   into  cir- 
cumstances extremely    perplexing.      How  becoming  it  is  to  in- 
vestigate and  examine  with  care,  the   history  of  every  disease 
before  operating,  and  to  ascertain  the  solt  or  solid,  the  fixed  or 
moveable  state  of  a  tumour,  its  probable  connections  ana  even- 
tual dangers  :  we  should  be  aware  ot  attempting  (which  is  indeed 
equivalent  to  promising)  to  extirpate  a  tumour,   which,    though 
apparently  moveable,   is  only  seated    on  a  moveable  bone  :   we 
should  be    careful  not  to  promise   a  cure  where,  perhaps,  the 
joint  is  destroyed  :  not  to  enter  upon  a  painful   and  exhausting 
operation,   m  a   case  where    nothing  but  amputation  can  avail. 
In  a  case  such  as  I  have  just  described,  it  should  be  recollect- 
ed, that  the  metacarpal  bones  lie  very  deep  in  the    hand,  hive 
a  considerable  latitude  of  motion,  and  may   communicate   that 
motion  to  the  tumour  ;  the  circumstances  of  this  tumour  and  its 
history  were  such  as  might  deceive  the  most  circumspect,  the 
turning  of  the    radius  conveyed  an    idea  ot  the  tumour   being 
moveable  ;  the  elastic  and  cartilaginous  feeling,  that  it  had  no- 
thing extraordinary  in   its  nature  ;  the  sac,  when  the  surgeon 
had  dissected  down  to  its  root,  was  suth  as  gave  him  reason  to 
believe  it  was  but  in  part  ossified  ;  tht  fat  which  he  scooped  out 
from  its  cavity,  that  it  was   merely  a  steutome  ;  it  was  not  till  he 
felt  with  his  finger  the  ball  of  carpal  bones  naked,   that  he  knew 
the  joint  to    be  diseast  d  ;  he  had  every  apology  tor  his  mistake, 
for,   in  a  disorder  of  no  more  than  six  months  duration,  he  had 
no  reason  to  believe  there  could  exist  such  universal  destruction 
of  the  joint  and  of  the  radius. 

But  a  charitable  endeavour  to  save  the  hand  of  a  poor  and 
labouring  man,  even  when  it  involves  us  in  a  severe  and  fruit- 
less operation,  is  not  the  worst  error  ;  the  surgeon,  alarmed  by 
the  uncouth  appearance  of  a  hand  deformed  by  such  disease, 
and  not  calculating  with  due  deliberation  the  individual  bones 
that  are  affected,  might  rashly  amputate  the  whole  hand,  where 
an  useful  part  of  it  might  be  preserved.  Among  the  cases  of 
this  nature  that  stand  recorded,  is  one  by  S.vcrinus,  short,  in- 
deed, but  not  the  less  interesting  :  "  Hveronimus  Damianus, 
a  youth  about  twent\ -two  years  ol  age,  crooked  and  scruggv, 
and  of  a  puny  habit  of  body,  had  his  right  hand  so  enlarged  as 
to  be  a  burden  too  great  for  him  to  bear  :  in  lying,  he  laid  it 
above  his  head,  walking,  he  carried  it  with  difficulty  on  his  other 
hand  :  it  was  diseast  d,  chit  fl\  by  the  enlargement  of  the  pha- 
langes of  four  of  the  fingers  ;  the  individual  tumours  you  would 
have  likened,  in  respect  of  size,  to  lemons,  in  respect  of  colour, 
to  rotten  apples,  being  large,  globular,  and  livid  :  these  knobs. 


392 


Of  the  Tumours  of  the  Bones. 


or  enlargements,  were  plaited  over  each  other,  and  the  points  of 
the  nails  projected  like  claws  from  the  extremities  of  the  seve- 
ral tumours."     Men  of  ordinary  genius  and  resources  no  sooner 
stumble  upon  a  difficulty  than  they  are  alarmed,  and  fear  mag- 
nifies every   danger  that  is    likely  to   affect  their   reputation  or 
practice.     Many  surgeons,  in  a  case  like  this,  fearful  lest,  after 
a  partial    operation,  the     disease   should    return,  would  have 
straightway  chopped  off  the  hand.     Severinus  acted  quite  other- 
wise :  cutting  off  each  finger  by  the  last  joint,  by  which  it  is 
united  with  the  carpus,  he  burnt  the  roots,  and  brought  the  parts 
to  a  sound  and  healthy  cure  :  he  thus  preserved  the  hand,  i.  e. 
the  carpus  and  the  thumb,  the  form,  and  something  of  the  use 
of  the  part,  for  such  a  stump  antagonising  the  other  hand,  and 
assisting  it,  would  be  very  precious.     Enormous  as  this  tumour 
was,  Severinus  had  the  skill  and  courage  to  save  at  least  the 
patient's  thumb  :  and  we  have  the  consolation  to  learn,  from  the 
case  of  this  unhealthy  and  crooked  creature,  plainly    disposed 
to  diseases  of  the  bones,  in  whom  the  spine  was  deformed,  and 
the   tumour  of  the  hand   spontaneous,   that  it  is  possible  even 
where  our  incisions  can  hardly  carry  us  beyond  the  immediate 
limits  of  the  disease,  to  accomplish  a  cure. 

In  the  sketch  of  this  hand,  you  will  remark,  that  the  bones 
are  alone  diseased,  that  the  several  knobs  or  tubercles  represent 


ma, 


DRAWINGS    FROM    SEVERINUS. 


Of  the  Tumours  of  the  Bones.  393 

the  several  phalanges  or  joints  of  the  fingers  ;  that  the  hand  and 
wrist  (a)  are  dwindled,  while  the  tumours  (c.  d.  e.  )  represent 
the  several  joints  of  the  ring-finger,  which  had  far  exceeded  the 
rest  in  size,  forming  the  chief  bulk  of  the  tumour  :  the  elonga- 
tion of  the  whole  hand,  demonstrates  the  growth  of  the  bones 
in  every  direction. 

But  extension  such  as  this,  especially  when  proceeding  from 
the  high  action  of  vessels,  must  end  in  ulceration,  which  is  the 
natural  conclusion  of  the  disease.  The  ulcer  is  fetid  and  ca- 
rious, affecting  at  once  the  bone  and  the  flesh,  and  so  ruinous 
to  the  health  that  amputation  cannot  be  delayed.  Such,  for  ex- 
example,  is  the  case  communicated  to  Severinus  by  Larch^eus, 
accompanied  with  a  drawing  :  it  seems  to  have  been  a  tumour 
of  enormous  size  indeed,  involving  all  the  carpal  and  finger- 
bones,  very  massive  and  tuberculous,  the  hand  weighing  no 
less  than  seven  pounds  ;  the  bones  were  thoroughly  diseased. 
This  irregular  mass  breaking  out  in  its  centre  (in  the  middle 
of  the  carpus)  into  ulceration,  destroying  not  only  the  fleshy 
parts,  but  the  bones,  there  ensued  a  hectic  fever,  when  the  man 
betook  himself  to  the  hospital  of  St.  James  for  incurables,  and 
solicited  to  have  his  hand  amputated,  which  otherwise  he  would 
not  have  parted  with,  for  he  was  a  pauper,  and  lived  by  ex- 
posing this  monstrous  mass  of  disease. 

So  desperate  do  I  account  this  kind  of  tumour,  when  accom- 
panied with  any  general  disease  of  the  bones,  and  so  loathsome 
are  the  carious  ulcers,  which  sooner  or  later  ensue,  that  I  al- 
ways think  it  a  consolation  when  the  disease  is  in  any  degree 
local,  even  though  it  admit  not  of  saving  the  hand  by  any  par- 
tial operation  ;  if  it  allow  of  our  saving  the  patient's  life  by  an\- 
putation,  I  think  it  a  special  piece  of  good  fortune.  How  little 
it  was  in  our  power  to  save  the  patient  whose  wrist  is  drawn 
on  the  same  page  with  this  of  Severinus,  you  will  perceive 
from  the  following  notes  of  his  case  :  "  His  wrist  is  deformed 
and  loaded  with  a  tumour,  or  rather  a  congeries  of  tumours, 
surrounding  the  joint,  knobby,  hard,  immovable,  of  a  rocky 
firmness,  and  plainly  proceeding  from  the  bones,  both  radius 
and  ulna  :  the  arm  is  weakened  by  the  tumour,  the  wrist  al- 
most powerless,  the  hand  dwindled  from  want  of  use.  The 
man  is  about  twenty-six  years  of  age,  a  weaver  by  trade,  born 
with  this  disease,  and  now  in  a  condition  which  hardly  admits 
of  any  alleviation.  This  tumour  of  the  wrist  was  observed 
even  at  his  birth  ;  it  was  then  very  small,  and  waxed  slowly  and 
gradually  to  its  present  size  :  from  year  to  year  the  tendency 
o  disease  became  more  and  more  conspicuous,  tumours  suc- 
tessively  formed  on  various  parts  of  his  body.  The  bones  of 
his  fingers,  ribs,  legs,  are  deformed  with  tumours  of  the  same 

3   D 


394-  Of  the  Tumours  of  the  Bones. 

rocky  firmness  ;  one  of  these  arising  from  one  of  the  ribs,  is  of 
a  most  singular  form,  projecting  from  the  flat  rib  like  the  han- 
dle of  some  instrument,  and  sticking  directly  out.  These  va- 
rious bony  tumours,  which  have  appeared  in  regular  succes- 
sion, and  grown  slowlv,  have  been  hitherto  void  of  pain,  and 
have  never  yet  prevented  his  daily  labour  ;  but  during  the  in- 
clement weather  of  last  winter,  and  taking  mercury  for  a  slight 
venereal  affection,  the  tumours  on  the  left  leg,  whether  from 
the  imprudent  administration  of  the  remedy,  or  some  lurking 
taint  of  the  disease,  became  so  extremely  painful,  that  he  was 
disabled  from  work,  confined  to  bed,  and  is  now  in  the  infir- 
marv.  The  papilla,  or  prominent  parts  represented  in  the  draw- 
ing, are  the  apices  of  those  rocky  and  firm  tumours,  which  are 
somewhat  pointed;  and  each  prominent  point  is  discoloured, 
so  as  to  assume  the  form  of  a  common  pimple,  but  very  fiery 
and  red.  The  painful  tumours  of  the  left  leg,  are  in  like  man- 
ner reddened  ;  the  whole  skin  investing  them,  is  inflamed  ;  the 
complexion  in  short  of  these  tumours  is  such,  as  demonstrates 
the  approach  of  that  ulceration,  which  is  to  convert  each  tu- 
mour into  a  loathsome,  fetid  and  carious  sore." 

Though  I  have  upon  my  recollection  many  proofs  of  tumours 
of  this  nature,  being  altogether  void  of  pain  ;  yet,  I  have  a  pre- 
possession, that  wherever  there  are  acute  pains  in  the  bones, 
there  is  actually  a  tendency  to  such  tumours;  the  close  connec- 
tion of  pains  and  tumours  in  venereal  cases,  vindicates  my  sus- 
picion, and  I  believe,  that  when  a  patient  speaks  of  rheuma- 
tism in  his  bones,  and  feels  it  deep-seated  with  oppressive  pain 
affecting  the  whole  limb,  the  disease  is  actually  seated  in  the 
centre  of  the  limb,  and  substance  of  the  bone  :  of  one  very  sin- 
gular case  of  this  nature,  I  find  I  have  taken  short,  but  accurate 
notes:  "John  M'Donald  went  early  in  life  an  apprentice  to 
the  West- Indies;  he  was  then  a  stout  young  man,  and  in  his 
profession,  as  stone-mason,  had  a  gang  of  workmen  under  his 
charge  ;  and  during  a  period  of  ten  years,  which  he  spent  in 
that  climate,  had  suffered  no  less  than  ten  successive  and  se- 
vere attacks  of  ague  and  fever,  and  had  suffered  much  from 
dysentery.  He  is  married,  and  has  been  so  many  years  ;  he  is 
a  sober  and  respectable  man,  apparently  fifty  years  of  age  ;  ne- 
ver had  venereal  complaints,  never  had  general  rheumatism, 
nor  indeed  any  other  pains  in  his  bones,  but  that  which  I  am 
now  about  to  describe. 

M  He  had  suffered  very  violent  pains  about  his  shoulders 
and  arms,  but  especially  in  the  left  humerus,  for  the  space  of 
a  year ;  those  pains  had  in  some  degree  ceased,  and  the  pain 
in  the  left  arm  had  been  little  distressing  for  three  months,  when 
one  day,  at  a  quarterly  meeting  for  the  regulation  of  a  common 


F.  595. 


Fig  i 


Jig. -2 


Kk'.;uny,.l?' 


Of  the  Tumours  of  the  Bones.  395 

subscription  fund,  or  society  subscription  for  the  relief  of  dis- 
tressed members,  a  little  girl  of  five  years  old,  being  in  the 
room,  he  lifted  her  over  one  of  the  benches,  and  in  the  moment 
of  doing  so,  felt  a  pain  so  sudden  and  acute,  that  he  could  not 
be  persuaded  but  that  some  one  had  hit  him  a  smart  blow  from 
behind,  across  the  arm;  bespoke,  he  says,  very  testily,  and 
could  not  help  crying  out,  that  by  that  silly  trick  they  had  raised 
his  old  pain,  which  instantly  became  more  violent  than  ever. 
From  that  moment  he  was  incapable  of  raising  his  arm  to  his 
head  ;  his  pain,  upon  every  occasion,  of  coughing,  laughing,  or 
moving  hastily,  is  excessive  :  but  when  at  pcrtect  rest,  he  has 
no  pain.  From  this  period  a  swelling  began  to  arise,  occupy- 
ing gradually  the  upper  and  middle  parts  of  the  humerus,  sur- 
rounding it  like  the  lump  of  clay  and  straw  which  is  wrap- 
ped round  a  grafted  tree."  In  this  very  singular  case,  I  have 
little  doubt,  that  the  fibres  at  the  origin  of  the  triceps,  and  in- 
sertion of  the  deltoid  muscles  had  given  way,  in  consequence 
of  the  diseased  state  of  the  periosteum,  and  tendons,  where 
they  are  implanted  into  the  humerus  and  that  from  such  injury 
the  tumour  had  arisen  ; — the  bone,  I  doubt  not,  is  carious  with- 
in, supported  only  by  this  shell  or  new  secretion ;  I  could  bend 
the  arm  gently,  and  could  perceive  that  the  sac  of  bony  secre- 
tion, which  at  first  seemed  perfect  and  firm  bone,  is  in  part  car- 
tilaginous, and  yields  ;  the  arm  bends  at  this  thickened  pait 
with  a  sort  of  elasticity :  having  one  day  committed  his  arm 
for  examination  to  a  very  brutal  surgeon,  and  turned  to  go 
away  while  he  was  thus  employed,  he  called  me  back,  with 
great  exultation,  to  shew  me,  that  he  had  been  able  to  bend  my 
patient's  arm  to  an  obtuse  angle,  so  as  to  put  the  fact  of  the  se- 
paration of  the  bones,  and  the  flexile  and  elastic  nature  of  the 
tumour,  beyond  dispute;  a  favour,  which  I  acknowledged,  I 
fear,  in  a  very  ungracious  manner. 

I  have  given,  along  with  the  drawing  of  the  wrist  of  the 
man  whose  whole  osseous  system  was  diseased,  one  from  Mr. 
jVIery,  ot  the  hand  of  a  youth  of  sixteen,  which  had  attained  to 
a  prodigious  size  and  monstrous  form  ;  it  weighed,  alter  am- 
putation, from  six  to  seven  pounds  ;  it  was  one  deformed  mass 
consisting  of  three  protuberances  of  various  magnitude  ;  the 
largest,  (a  figure  1.)  belonging  to  the  ring-finger,  appeared 
chiefly  on  the  back  of  the  hand,  and  was  seven  inches  in  diame- 
ter; the  tumour  next  in  size  (Z>),  proceeding  from  the  raid- 
linger,  was  six  inches  in  diameter;  that  proceeding  from  the  lit- 
tle finger,  was  four  inches  in  diameter,  and  is  seen  only  in  the 
second  drawing,  viz.  in  the  skeleton  of  the  hand  at  (r).  The 
skin,  wherever  it  lay  over  these  tumours,  was  coarse,  with 
deeper   ridges : — the  suriacc  was  deformed  with    deep  ulcers, 


396  Of  the  Tumours  of  the  Bones. 

affecting  not  the  soft  parts  onlv,  but  the  bones :  though  from  the 
uusi^htly  appearance  of  the  whole  mass,  it  was  by  many  pro- 
nounced cancerous,  yet  these  sores  were  in  truth  red,  granu- 
lating, and  healthy  ;  even  the  deepestot  thtm  were  void  otpain, 
and  the  veins  of  the  hand,  usually  swelled  in  cancerous  tumours, 
were  flat.  Through  the  skin,  which  was  thin  from  extension, 
the  tumours  felt  very  firm  and  osseous  ;  the  lad  assigned,  as 
the  cause  of  this  monstrous  deformity,  the  hand  being  bruised 
at  the  early  age  of  six  years  :  he  was  entirely  well  ol  this  hurt 
before  the  hand  began  to  grow,  but  it  began  soon  after  the  ulce- 
ration healed  to  increase  in  size,  and  continued  to  enlarge  for 
ten  years.  The  hand,  he  had  remarked,  during  the  two  latter 
years,  had  grown  more  than  in  all  the  eight  preceding.  Upon 
dissecting  the  amputated  hand,  the  tumour  was  found  to  lie  ex- 
clusively in  the  bones  ;  the  greatest  tubercles  were  merely  en- 
largements of  the  first  and  second  phalanges  of  the  three  last 
fingers  ;  those  joints  of  the  fore-finger  and  thumb  being  sound. 
The  joints,  in  this  instance,  at  the  same  time  that  they  were 
enlarged,  were  motionless  from  being  anchylosed  ;  but  their  ar- 
ticulations with  the  metacarpal  bones  were  fixed,  by  the  rigid 
state  only  in  which  the  tendons  were,  from  motion  being  so 
many  years  suspended.  The  shell  of  these  tumours  was  thin, 
the  internal  parts  crossed  by  bony  fibres,  cellular,  and  caver- 
nous, were  filled  with  a  juice  resembling  the  jelly  of  meat  in 
colour  and  consistence ;  and  it  is  singular,  that  the  carpal  and 
metacarpal  bones  being  but  slightly  affected,  and  the  extreme 
phalanges  on  which  the  nails  are  implanted,  entirely  sound,  the 
intermediate  bones  were  enlarged  to  this  prodigious  degree. 
One  only  of  the  metacarpal  bones,  that,  viz.  which  supports  the 
mid-finger,  was  diseased,  and  so  far  enlarged  as  to  be  an  inch, 
and  a  half  in  diameter,  studded  with  some  small  tubercles,  and 
exposed  in  part  by  carious  ulcers.  The  carpal  bones  were  per- 
fectly SOUND. 

There  is  no  case  from  which  some  lesson,  more  or  less  im- 
portant, may  not  be  deduced  :  all  this  description  is  interesting. 
The  two  drawings  represent,  1st.  the  deformed  and  fetid  mass, 
the  enormous  tumours,  the  roughened  skin,  and  the  ulcers  pe- 
netratirg  into  the  cavities  ot  these  tumours.  2d.  The  skeleton 
of  the  hand,  exhibiting  the  respective  tumours  of  the  middle, 
ring,  and  little  fingers,  and  the  heart-shaped  enlargement  (c) 
of  the  metacarpal  bone  of  the  middle  finger,  is  also  singularly 
interesting,  demonstrating  that  the  whole  tumour  is  bone,  per- 
manent, and  firm,  and  not  an  expansion  of  the  phalanges,  but 
a  new  secretion.  The  bone  of  the  fore-finger  was  not  so  much 
diseased  as  deformed,  dwindled  in  size,  and  bent  into  an  arch, 
nnder  the  pressure  of  this  tumour:  the  thin  shells  of  bone,  the 


Of  the  Tumours  of  the  Bones.  397 

cancellated  texture  of  the  tumours,  and  the  carious  openings, 
are  also  well  represented. 

From  this  description  we  learn,  that  it  is  not  during  the  pe- 
riod of  high  and  violent  action  that  tumour  is  generated.  Mat- 
ter is  added  to  matter  in  the  animal  body  by  a  slow  process; 
whereas  high  action  terminates  in  suppuration,  gangrene,  or 
some  violent  crisis.  The  state  of  vascular  action,  which  is 
slower,  more  nearly  approaching  to  that  ot  health,  resembling 
the  slow  accession  of  disease,  or  the  remains  ol  high  action  not 
yet  subsided,  is  more  favourable  to  the  gent  ration  ol  tumour  ; 
for  such  moderated  action  does  not  injure  the  structure  ol  the 
part,  does  not  interrupt  nutrition,  allows  the  secretion  ol  new 
parts  to  proceed,  and,  in  so  far  as  it  is  accelerated  beyond  the 
natural  state,  augments  it.  You  will  take  notice  that  it  was  not 
while  this  hand  was  inflamed  and  suppurating,  (tor  it  seems  to 
have  been  not  merely  bruised  but  wountkd,  il  avoit  etc  gueri 
parfaitement  de  aa  blcssure  mais  peu  de  temps  apres  sa  gueri- 
son,)  but  after  the  cure  was  so  far  complete,  and  the  increased 
action  not  yet  subsided,  that  his  hand  began  to  swell. 

This  case  brings  an  important  practical  question  to  a  very 
short  issue,  for  these  drawings  prove  the  local  nature  ol  the 
disease,  viz.  that  it  is  merely  in  the  bones,  always  in  the  heads 
or  solter  parts,  that  the  disease  is  seated :  that  the  phalanges  of 
the  lingers,  which  are  peculiarly  spongy,  and  the  lower  heads 
of  the  radius  and  ulna  are  most  liable  to  disease.  Mery  con- 
fesses (without  being  conscious  how  far  in  that  case  he  was  to 
blame)  that  one  half  of  the  hand  was  apparently  sound  ;  and  that 
upon  dissection,  the  finger  and  thumb  were  lound  in  their  sound 
and  natural  state.*  How  then  can  we  acquit  him  of  rashness 
in  smiting  off  the  hand  of  a  boy  of  eighteen  years  of  age,  with 
youth  and  health  on  his  side,  and  all  the  world  before  him, 
when,  by  a  less  painful  operation,  he  might  have  saved  his 
thumb,  fore-finger,  and  wrist  ?  Surely  we  may  pronounce  him 
wrong,  if  there  be  one  word  of  truth  in  the  case  of  Severinus,  in 
which  the  thumb  and  carpus  were  saved. 

Of  the  various  questions  which  cases  of  this  nature  suggest 
there  is  one  which  I  am  almost  afraid  to  investigate.  When  in 
an  adult  such  tumours  appear,  we  have  reason  to  hope  that  they 
may  be  local,  and  that,  by  cutting  out  the  bone,  we  may  extir- 
pate the  disease.  Even  when  such  tumours  grow  at  once 
on  various  parts,  we  may,  by  circumstances,  be  induced  to  ex- 
tirpate the  individual  tumours,  and  cauterize  their  roots  ;  but 
what  shall  we  do  when,  in  childhood,  the  disease  manifests  it- 


*  Ccpcndant  la  moitic  ou  environ,  en  paroifloit  faine  cxterieurement,  et  le  Pouce 
■"  l'Indcx  dans  leur  ctat  naturel. 


398  Of  the  Tumours  of  the  Bones. 

self  in  various  parts  of  the  osseous  system  ?  when  all  parts  of 
the  bones  seem  (like  the  cellular  fat  of  some  diseased  people) 
disposed  to  excrescences  ?  When  tumour  after  tumour  appears 
in  quick  succession?  and  the  fingers,  the  hands,  the  wrist,  the 
elbows,  the  toes,  the  tibia,  become  affected  ?  when  both  hands 
are  crooked  alike,  griffin's  claws  in  every  finger  ;  and  when  the 
arms  and  feet  begin  to  be  deformed  ?  Shall  we  remain  specta- 
tors of  the  ruin  of  joint  after  joint,  in  a  fine  healthy  boy  ?  shall 
we  calmly  look  on  till  each  tumour  has  acquired  its  utmost  mag- 
nitude, suppurated,  and  burst  into  that  state  of  loathsome  ca- 
ries which  must  close  the  scene  ?  or  anticipate  this  inevitable 
termination,  amputate  and  cauterize  those  tumours,  and  even- 
tually subject  our  art  to  discredit,  and  ourselves  to  the  personal 
reproach  of  trying  rash,  severe,  and  yet  lingering  operations  ? 
Although,  in  a  situation  so  hopeless  we  must  be  sorely  tempt- 
ed, yet  duty  and  charity,  I  fear,  compel  us  to  refrain. 

The  rapid  manner  in  which  bone  is  secreted  and  accumulated 
to  an  astonishing  bulk,  is  one  of  the  most  singular  phenomena 
that  occurs  in  the  living  body.  The  instance  I  am  now  going 
to  relate  will,  I  am  sure,  appear  surprising,  but  it  is  selected 
for  a  far  better  purpose,  to  serve  as  an  example  of  the  difficulty 
we  sometimes  find,  in  saving  the  patient's  life,  even  where  the 
the  disease  is  local,  and  growth  of  the  bone  sensible  and  rapid. 
I  fear  too  it  is  one  of  a  thousand  examples,  of  a  man  lost  in  the 
prime  of  life,  and  dying  a  most  loathsome  and  miserable  death, 
from  the  reluctance  of  the  surgeon  to  charge  himself  with  the 
fate  of  such  a  patient,  or  to  predict  the  future  consequences  of 
a  tumour  while  it  is  yet  small. — It  is  the  case  of  a  young  man, 
"  committed  to  my  humanity  and  skill,"  by  Dr.  Forbes,  of 
Inverness. 

Alexander  Macdonald,  a  Highlander  from  Fort  Au- 
gustus, a  tall  and  handsome  lad,  exceeding  six  feet  in  height, 
and  uncommonly  athletic,  was  put  to  the  Perth  Academy  for 
his  education  in  writing,  book-keeping,  and  such  other  parts  of 
learning  as  might  qualify  him  for  a  counting-house,  as  it  was  in- 
tended to  send  him  to  America  a  clerk  in  the  North- West 
Company  in  the  fur  trade.  In  running  violently  at  tennis,  on 
the  academy  green,  he  fell,  and  hurt  his  shoulder  :  it  was  such 
a  bruise  as  often  happens  from  a  fall,  without  entailing  the 
slightest  ill  consequence,  beyond  the  first  pain  and  swelling :  the 
skin  was  blackened  by  the  bruise,  and  the  joint  was  sprained  ; 
he  had  excessive  pain  along  the  whole  arm  for  twenty-four 
hours,  but  it  vanished  gradually: — He  imagined  himself  well ; 
he  had  recovered  every  thing  but  the  strength  of  his  arm  j  but 
after  the  violence  of  the  pain,  (which  lasted  no  more  than 
twenty-four  hours,)  was  gone,  such  weakness  remained,  that 


Of  the  Tumours  of  the  Bones.  a99 

though,  from  his  great  strength,  he  could  lift  perpendicularly 
such  weights  as  others  could  not  move,  yet  he  could  never 
raise  his  arm  to  his  head. 

I  was  at  pains  to  question  his  father,  a  respectable  old  man, 
concerning  the  part  which  received  the  injury;  and  he  clearly 
and  decidedly  affirmed,  that  it  was  not  the  shoulder-joint,  but 
the  middle  of  the  bone  of  the  arm  that  received  the  shock,  it 
was  along  the  whole  of  the  arm  that  he  felt  the  pain,  and  could 
distinguish  the  marks  of  the  bruise.  The  pain  bad,  after  its 
first  violence,  totally  ceased,  as  if  the  part  had  sustained  no  per- 
manent injury,  and  he  believed  himself  well ;  it  was  exactly  at 
the  end  of  "a  month,  that  the  pain  returned,  and  fixed  in  the 
joint,  with  a  very  distressing  sense  of  weakness,  so  that  he  could 
not  raise  his  arm  at  all;  if  he  meant  to  put  on  his  hat  with  it, 
he  had  to  raise  it  with  the  other  hand,  and  when  thus  raised,  if 
he  lowered  it  again  without  support,  the  moment  it  fell  unsup- 
ported below  the  level,  it  descended  like  lead.  Still  he  could 
lift  perpendicularly  a  very  great  weight :  but  from  this  second 
period  of  pain  we  must  date  the  disease.  The  whole  arm  swel- 
led, but  especially  about  the  shoulder;  his  cries  and  shrieks 
were  wild  and  melancholy  ;  living  in  a  remote  part  of  the  High- 
lands, it  is  natural  for  the  father  to  express  himself  in  the  fol- 
lowing words,  which  he  invariably  uses  when  I  question  him  in 
regard  to  the  degree  of  pain,  "  Sir,  there  was  no  hour  of  the 
night  nor  day  in  which  you  could  not  hear  his  wild  cries  miles 
off."  He  represented  the  particular  pain,  by  saying,  *•  it  seem- 
ed as  if  he  had  been  bored  with  hot  irons  ;  and  his  cries  were 
so  unceasing,  as  well  as  so  piercing,  that  though  they  lived  in  a 
very  long  house,  they  had  no  sleep  from  this  time  forward." 

That  such  had  been  his  condition  no  one  could  doubt,  who 
saw  him  before  his  death;  for  the  swelling  kept  equal  pace  with 
these  dreadful  sufferings;  at  first  the  arm  seemed  chiefly  to 
swell  from  the  shoulder-joint ;  gradually  the  whole  arm  swelled, 
and  the  fore -arm  and  hand  dwindled.  His  body,  before  lusty, 
and  strong,  was  wasted  with  the  agony  and  want  of  rest.  Yet 
even  at  this  time,  when  the  arm  was  monstrously  swelled,  and 
before  it  was  entirely  oppressed,  or  the  fore-arm  wasted,  he 
could  lift  as  heavy  a  weight  with  the  left  arm  as  with  the  right ; 
and  even  to  the  last  stage,  that  in  which  I  saw  him,  his  hand 
was  strong  to  grasp.  In  the  first  four  months,  the  upper  part 
of  the  arm  had  so  increased  in  size,  that  the  prominent  part  ex- 
ceeded the  size  of  his  head,  but  now,  at  the  end  of  nine  months, 
it  greatly  exceeds  in  size  his  emaciated  body. 

When  I  went  to  receive  this  poor  lad,  I  found  hirn  lying 
deep  in  the  hold  of  a  small  sloop,  in  which  he  had  been  trans- 
ported from  Inverness,  laid  on  a  coarse  mattress,  and  bolstered 


400  Of  the  Tumours  of  the  Bones. 

up  against  the  shelving  side  of  the  vessel ;  and  when  the  clothes 
were  lifted,  I  solemnly  declare,  that  I  hardly  knew,  at  first, 
what  it  was  that  I  saw,  which  was  the  tumour,  and  which  his 
body,  or  how  to  connect  in  imagination  the  one  with  the  other. 
He  by  in  an  inclined  and  irregular  posture,  extremely  languid, 
and  hardly  able  to  articulate  ;  his  head  inclining  to  one  side,  the 
a  first  exposed  bv  lifting  the  clothes,  might  be 
for  his  body  ;  in  respect  of  size,  it  was  of  a  suitable 
.  and  when  the  lean,  yellow,  and  emaciated  thorax  was 
.  the  tumour  seemed  so  much  to  exceed  it  in  size, 
with  a  shining  surface  and  brilliant  colour,  that  at  first  I  was 
more  confounded  than  shocked,  so  impossible  was  it,  in  the 
first  moments,  to  consider  of  it  as  a  tumour,  or  to  see  its  rela- 
tion to  the  arm.  The  fore-arm  was  dwindled  and  shrunk,  and 
vtcd  from  the  tumour  at  a  strange  and  unnatural  distance 
from  the  shoulder  :  the  veins  were  swelled,  like. those  of  a  horse's 
belly  :  large  fungous  tumours,  as  big  as  oranges,  projected  in  a 
group  from  the  outside  of  the  arm,  at  the  place  where,  about 
two  months  before,  a  large  abscess  had  burst ;  and  such  was 
the  fetor  of  the  matter  running  from  under  these  fungi,  and 
the  languor  of  this  poor  emaciated  creature,  that  I  had  no  thought 
for  the  present,  but  how  to  get  him  conveyed  alive  to  town. 
After  a  few  days,  when  he  was  somewhat  recovered  from  the 
fatigues  of  his  voyage,  I  proceeded  to  write  down  the  historv, 
and  examine  the  actual  state  of  this  tumour. 

I:  consisted  chiefly  of  bone,  was  little  cartilaginous  ;  hardly 
in  any  part  elastic  or  yielding,  and  discharging  matter,  not  from 
any  superficial  abscess,  but  apparently  from  the  centre  of  this 
enormous  mass.  I  had  every  reason  to  believe,  that  the  bone 
and  the  joint,  which  certainly  were  neither  broken  nor  dislo- 
cated, had  been  generally  injured,  not  merely  by  the  sho6k, 
but  by  the  bruise :  that  the  parts  nearest  the  bone,  and  con- 
nected with  it  by  the  periosteum,  had  been  bruised  and  in- 
flamed :  that  the  extreme  pain  for  the  first  twenty-four  hours, 
indicated  on]  l=nce  of  the  immediate  injury,  but  the 

vascular  action  which  succeeded,    at  the  distance  of    a 
month,  proved  how  deeply  the  circulation  of  the  bone  was  af- 
fected, and  caused  that  osseous  secretion  which  generated  this 
prodigious  shell  of  bone ;    while    the    shaft  of  the  humerus, 
from   the   periosteum   of  which    this  callus  had  been  secreted, 
was  in  par:  destroved  bv  an  ulcerating  process  within  :   that  the 
ration,  deep  seated,  not  only  in  the  bone,  but  in  the  joint, 
occasioned  those  excruciating  tortures   which   were  announced 
by  wild  and  desperate    cries,  night  and  dav  :  that  the  matter 
bursting  at  last  through  even   obstacle,    had    made    its    way 
gh  that  ulcerated  part  of  the  surface,  which  is  studded  with 
pus  excrescences. 


Of  the  Tumours  of  the  Bone^ .  401 

This  bursting  out  of  the  matter  brought  relief  from  the  pain  ; 
he  now  lay  in  a  state  of  extreme  languor,  moaning  and  slum- 
bering ;  you  found  it  painful  even  to  question  him,  he  was  so 
feeble  ;  he  fell,  after  a  few  broken  answers,  into  a  slumber  of 
mere  debility,  and  closed  his  eyes  as  exhausted;  and  while  I 
took  a  sketch  of  his  posture,  and  of  the  proportions  of  this 
prodigious  tumour,  he  slumbered  continually.  His  extreme 
weakness  precluded  every  practical  experiment,  and  left  for 
our  discussion  the  speculative  question  only  ;  u  In  a  case  so 
deplorable  and  hopeless,  what  should  we  have  done  at  an  ear- 
lier stage,  when  the  patient's  strength  was  more  entire,  and 
youth  and  vigour  (for  he  was  but  twenty-one  years  of  age)  on 
his  side  ?" 

Here,  for  the  first  time,   I  felt  that  a  bony  tumour  might,  by- 
advancing  to  the  trunk  of  the  body,  preclude  amputation  as  en- 
tirely as  aneurism  of  the  subclavian  artery  !    Tnat  the  question 
here  to  be  resolved  was  not,  whether  we  might  dire   to  ampu- 
tate at  the  shoulder-joint,  the  question  was  of  amputating  the 
scapula   also,  an  J  along  with  it  a   tumour,  exreeding  in    size 
even  the  trunk  of  the   bo  ly  !  and  the   accident  mentioned  bv 
Cheselden,  (an  accident    which  has  often  happened  since)  of 
Wood,  the  miller,  whose  arm,  scapula  and  all,  was  rudelv  and 
suddenly  torn  from  his  body,  could  not  but  come  into  our  recol- 
lection.    There  was  hardly  left  us  even  a  choice  to  exercise 
our  discretion  and  skill  upon  ;  for,  from  the  state  of  the  veins, 
large,  tortuous,  and  already  ulcerating,  and  so  numerous  as  to 
give  a  livid  colour  to  aimost  all  the  surface  ot  the  tumour  ;  it 
was  plain,  that  he  was  in  daily  p^ril  of  haemorrhagv,  and  that 
this  was  at  no  remote  period,  certainly  within  a  few  weeks,  to 
put  a  period  to  his  life  !  Could  there  then  be  a  question,  whe- 
ther to  wait  in  fear  of  that  h.emorrhsgy,  which  was  assuredly 
to  end  in  death,  or  to  risk  by  operating,  that  hemorrhagy  bv 
which  he  might  be  saved  alive  ?     For  my  part  I  had  not  the 
shadow  of  a  doubt  :  what  should  determine  us  in  anv  despe- 
rate case,  to  do  desperate  things  ?   Surely  the  possibility  of  safe- 
ty through  operation,  the  certainty  of  death  !   I  saw  it  possible, 
by  trying  first  the  subclavian  artery,  the  root  of  all  the  circum- 
flex arteries  of  the  shoulder  and  scapula,  to  prevent  any  alarm- 
ing degree  of  hcemorrhagv  ;  bv  ross  the  outer  end  of 
the  clavicle  to  get  command                       -ila,  and  turn  it  back, 
as  easily  as  the  flap  from  an  ordinary   stump  ;  to  tie  when   it 
was  cut,  the  artcri  .                      -          ilae,  ard  certainly  to  s--. 
rate  the  whole,  wi                                      th.     But  had  this  been 
an  enterprise  as  certainly   fatal  ai  the  C  _ction  itself, 
still  it  gave  some  chance  for  !      .      C                  a  the  justne*- 
this  reasoning,  moral  and  pi                        :uld  have  urged 


402  Of  the  Tumours  of  the  Bones. 

to  this  awful  trial,  and  devoted  myself  to  the  task  ;  but  he  was 
sunk  too  low  for  any  trial,  and  to  be  regarded  only  as  an  object 
of  charitable  care.  He  died  in  the  Royal  Infirmary,  of  hacmorr- 
hagy,  about  three  weeks  after  his  admission,  and  these  are  the 
notes  of  the  dissection. 

DISSECTION,  July  13th,  1806. 

"  Having  divided  the  integuments,  which  were  extremely 
thin,  we  found,  on  attempting  to  cleanse  the  tumour  from  one 
extremity  to  the  other,  that  it  was  of  a  substance  much  resem- 
bling callus  ;  in  many  places  it  was  so  firm  and  solid,  that  af- 
ter trying  in  vain  to  divide  it  with  a  strong  knife,  we  were  o- 
liged  to  betake  ourselves  to  the  common  amputation-saw. 

"  The  cells  of  this  bony  tumour  were  every  where  filled  with 
a  matter  resembling  thick  cheese  ;  the  tumour  itself,  from  its 
great  size,  and  the  entire  appearance  of  the  os  humeri,  seemed 
only  to  be  attached  to  that  bone  ;  but  upon  a  more  minute  ex- 
amination, was  plainly  a  production  from  its  substance.  The 
humerus  could  be  traced  through  the  whole  tumour  ;  but  en- 
larged, spongy,  and  ulcerated.  The  upper  part  of  the  scapu- 
la, the  acromion  process,  and  the  outer  end  of  the  clavicle, 
could,  during  life,  be  plainly  distinguished  to  be  enlarged,  and 
to  form  part  of  the  tumour;  and  upon  dissection,  all  the  bones 
forming  the  shoulder-joint  were  found  to  be  deeply  diseased. 
The  upper  and  most  bulky  part  of  the  tumour,  seemed  to  pro- 
ceed as  much  from  these,  as  from  the  os  humeri,  and  the  joint 
was  completely  anchylosed." 

There  is  a  period  in  every  such  case,  when  the  tumour  being 
still  of  moderate  size,  and  yet  requiring  an  operation  of  the 
most  desperate  and  unprecedented  nature,  viz.  the  amputation 
even  of  the  scapula  itself;  the  question  must  be  of  the  most  per- 
plexing and  agitating  nature.  The  surgeon  must  be  conscious, 
that  the  patient  is  to  die  a  loathsome  and  miserable  death  ;  yet 
it  is  a  consciousness  which  he  never  can  bring  home  to  the  mind 
of  the  patient  or  his  friends,  and  if  he  take  upon  himself  to 
urge  an  operation  so  desperate,  and  the  patient  should  die, 
the  slight  impressions  his  representations  have  made  vanish, 
the  danger,  which  was  distant  and  problematical,  has  been  ac- 
celerated by  his  misconduct ;  by  his  ill  success  he  is  condemned, 
and  never  can  it  be  put  out  of  the  minds  of  the  relations,  that 
the  patient  might  have  lived,  or  that  even  the  tumour  might 
have  burst  and  resolved  into  matter.  But  a  precedent  like  this, 
and  I  have  witnessed  and  could  relate  many,  solves  all  scruples, 
and  he  who  knows  the  constitution  of  such  a  tumour^  its  inevi- 


Of  the  1  amours  of  the  Bones.  403 

table  increase,  and  the  loathsome  end  of  the  sufferer,  will  not, 
I  believe,  shrink  from  his  duty.  This  case  is  highly  interest- 
ing, as  it  is  the  direct  consequence  of  a  very  ordinary  mischance, 
of  a  slight  fall,  and  a  bruise  importing  nothing  :  it  is  not  mere- 
ly a  prodigy  to  be  gazed  on,  but  an  important  precedent. 

Allow  me,  before  I  forsake  this  interesting  subject,  to  give 
you  one  document  in  practice,  from  the  universal  ignorance, 
or  wilful  neglect  of  which,  I  see  every  day  the  most  dismal  con- 
sequences. A  bone,  both  in  itself,  and  in  its  surrounding  vas- 
cular apparatus,  is  as  susceptible  of  inflammation,  and  while  it 
is  inflamed,  or  in  danger  of  being  inflamed,  should  be  as  deli- 
cately treated  as  the  soft  parts.  How  often,  how  continually 
you  have  seen  this  injunction  reversed,  I  need  hardly  remind 
you:  every  bruised  bone,  and  sprained  joint,  is  rubbed  and  di- 
ligently moved.  With  an  ignorant  and  stupid  fear,  of  the  joint 
losing  its  motion,  it  is  wrought  backwards  and  forwards  in  eve- 
ry direction  !  and  whatever  inflammation  is  begun,  is  never  per- 
mitted to  subside  !  Thus  a  military  gentleman,  whose  humerus 
was  diseased,  with,  I  doubt  not,  an  internal  caries,  (for  I 
have  dissected  such  cases,  and  kept  in  preparation  very  long,  a 
shoulder-joint  thus  diseased  internally,  which  betrayed  no  out- 
ward appearance  of  disease)  and  who  had  excruciating  pains,  a 
total  lameness,  a  singular  emaciation  of  the  whole  member,  and 
who  though  he  could  mount  his  horse,  could  not  endure  the 
motion  of  it,  even  at  a  foot  pace,  was  ordered  by  the  physi- 
cians he  last  consulted,  along  with  various  other  prescriptions,  to 
have  his  arm  turned  and  wrought  backwards  and  forwards  by 
his  servant  with  all  his  strength.  He  fainted  more  than  once, 
under  this  discipline,  and  fortunately  was  not  able  longer  to  en- 
dure what  must  have  killed  him  in  the  end  ;  by  completing  that 
caries  of  the.  joint  which  was  at  that  moment  just  remediable. 
He  came  from  Ireland,  and  put  himself  under  my  care,  and  by 
a  course  of  stimulant  fomentations,  by  bandaging  his  arm  to  his 
side  with  rollers,  as  closely  as  if  it  had  been  fractured,  and  by 
renewing  caustic  issues  all  round  the  acromion  process,  and 
head  of  the  shoulder,  and  keeping  them  running  for  six  months, 
he  is  now  almost  entirely  cured.  His  arm,  notwithstanding  the 
stricture  of  the  bandages,  has  recovered  its  flesh  and  firmness  ; 
he  can  raise  it  now  without  pain,  and  find  that  he  could  use 
it  with  confidence  :  but,  I  think  it  right  for  a  limited  term  to 
keep  him  safe,  with  the  arm  slung,  and  without  motion,  till 
every  tendency  to  disease  is  gone. 

A  young  lady,  whose  arm  I  have  been  obliged  to  amputate, 
fell,  at  the  age  of  fifteen,  from  a  table,  and  sprained  her  elbow- 
joint.  The  immediate  pain  was  just  such  as  is  usual  on  such 
slight   accidents;    it  subsided,  and  there  remained  only  that 


404  Of  the  Tumours  of  the  Bones. 

dead  and  heavy  pain,  and  stiffness  of  the  joint,  which  indicates 
that  the  ligaments  and  periosteum  are  not  yet  relieved  from  the 
inflammation,  and  which  requires  stimulant  fomentations:  per- 
haps a  caustic  issue,  and  perfect  rest :  what  was  directed  ? 
Why,  that  she  should  carry  all  day  long  a  heavy  dressing-iron 
in  her  hand,  to  straighten  the  joint  by  the  continual  extension, 
and  that  she  should,  by  frequent  exertions  of  swinging  this  load 
backwards  and  forwards,  with  the  help  of  a  servant  to  twist  and 
turn  the  joint,  try  to  recover  the  free  motion  of  it.  This  im- 
prudence has  almost  cost  her  her  life  :  the  internal  inflamma- 
tion was  never  permitted  to  subside  ;  the  joint  swelled,  burst 
out  in  fetid  ulceration ;  the  bones  and  the  joint  became  com- 
pletely carious;  paroxisms  of  inflammation,  new  suppurations, 
and  weeks  of  excruciating  pain  before  the  bursting  ot  each  ab- 
scess, reduced  her  to  the  lowest  extremity  of  weakness  :  she 
had  haemoptysis  and  every  appearance  of  confirmed  hectic,  and 
approaching  death,  when  a  consultation  dictated  the  amputation 
of  the  arm  as  the  only  possible  means  of  saving  her.  Since 
the  operation,  and  even  before  the  adhesion  of  the  stump  was 
complete,  she  had,  by  pleasant  sleep,  and  the  return  of  appetite, 
recovered  her  strength  and  freshness  of  complexion,  and  is 
now  in  perfect  health. 

Such  errors  are  so  commonly  and  thoughtlessly  committed, 
that  they  are  as  it  were  contagious;  we  do  what  we  see  daily 
done  before  us,  without  thought  or  reflection,  which  makes  a 
document  of  this  nature,  on  an  ordinary  occasion,  of  no  slight 
importance  to  the  young  surgeon. 


(  405  > 


DISCOURSE  XXII. 


ON  TUMOURS  OF  THE  NOSTRILS,  GUMS,  AND 
THROAT. 

JL  HOUGH  polypus  is  one  of  the  most  loathsome  and  fatal 
diseases,  it  is  described  in  terms  little  suited  to  convey  this 
idea  to  the  young  surgeon  ;  who,  while  he  reads  a  systematic 
author,  or  hears  a  lecturer  talk  in  slight  and  familiar  terms  of 
the  disease,  and  its  cure,  little  suspects  the  dismal  scenes  which 
are  passing  in  the  chambers  of  the  sick,  and  puts  his  hand  with, 
little  forethought  or  prudence,  to  operations  the  most  difficult 
for  a  man  of  experience,  the  most  impossible  for  an  unskilful 
person  to  perform. 

How  this  levity  of  manner  should  be  explained,  I  have  been 
at  times  doubtful,  and  am  now  perhaps  uncharitable  ;  but  I 
could  not  avoid  observing,  that  in  the  works  of  systematic 
writers,  this  appears  so  simple,  so  trivial,  so  harmless  a  dis- 
ease ;  it  is  represented  as  so  mild  in  its  ordinary,  and  so  incu- 
rable in  its  more  malignant  form,  that  the  chief  care  of  the 
surgeon  should  be,  to  make  a  just  prognostic,  and  act  with  re- 
serve and  prudence.  But  those  who  have  transmitted  to  us  the 
most  faithful  records  of  their  cases,  represent  a  far  different 
scene.  Polypus  appears,  in  their  juster  pictures,  to  be  one  of 
the  most  horrible,  the  most  incurable  diseases,  u  In  writings  of 
systematic  authors,  all  seems  simple  and  harmless,  and  the 
methods  of  cure  are  trifling  and  temporizing.  In  the  works  of 
original  authors,  the  methods  are  rude,  violent,  and  unrelent- 
ing :  rather  than  not  unroot  the  tumour,  thev  would  burst  up 
the  cells  of  the  face,  and  destroy  all  the  bones  ;  and  they  de- 
liberately debate  these  questions,  whether  we  should  not  split 
up  the  nostrils?  trepan  the  antrum  of  Highmorianum  ?  and  dig 
away  the  spongy  bones  ?  rather  than  fail  to  reach  the  roots  of 
the  tumour.  Whether  it  be  not  allowable  to  perform  bron- 
chotomy,  and  by  opening  the  trachea  procure  free  breathing  for 
the  patient,  while  these  more  cruel  operations  are  performing  ? 
This  is  a  text,  these  are  discrepancies,  on  which  it  becomes  us 
to  comment.  Those  who  have  heard  and  repeated  the  sa^  ing, 
that  polypus  is  in  general  a  mild  disease,  have  of  course  be- 


406       On  Tumours  of  the  XostrHs,  Gums,  and  Throat. 

lieved  that  these  are  cases  of  peculiar  malignity  ;  that  there  are, 
certain  polypi  which  the  surgeon  need  not  disturb,  and  should 
not  tamper  with,  and  others  which  he  assuredly  cannot  cure. 
But  were^this  conviction  ever  brought  home  to  the  mind  of  the 
surgeon,  then  should  his  good  offices  be  at  an  end  ;  surelv  we 
must  not  in  anv  case  pretend  to  meddle  with  a  disease,  which, 
if  mild  in  its  species,  we  should  not  irritate  ;  which,  if  malig- 
nant, we  cannot  cure  ?  But  I  have  some  experience  in  this  line 
of  practice,  and  some  judgment  in  this  department  of  reading; 
and  have  strong  suspicions  of  something  wrong,  if  not  unfaith- 
iul,  in  these  opposite  representations.  Polypus  is  never  mild, 
nor  ever  malignant;  time,  and  the  natural  growth  of  the  tu- 
mour, and  the  pressure  it  occasions  within  the  soft  and  bony 
cells  of  the  nostrils  and  jaws,  must  bring  ever)-  polypus  to  one 
invariable  form,  in  its  last  and  fatal  stage.  Those  who  are  em- 
ploved  in  recording  cases  on  unquestionable  facts,  give  us  the 
true  and  only  picture  of  diseases,  they  speak  of  none  which 
they  have  not  seen  ;  but  systematic  authors,  obliged  to  explain 
each  disease  in  its  order,  give  descriptions  of  diseases  widely 
distant  from  truth,  describing  what  manifestly  they  have  not 
seen,  and  explaining,  without  the  slightest  remission  of  their 
wonted  confidence,  what  they  have  not  learned  and  cannot 
know.  Whatever  you  might  learn,  (yet  that  would  be  in  an 
irregular  and  dangerous  wav)  from  books  of  cases,  be  assured 
you  might  read  those  systematic  authors,  (which  I  might 
name,  I  hope,  without  envy,  and  which  I  allude  to  without 
malice,)  from  sun-set  until  sun-rise,  without  conceiving  the 
vei  \  slightest  notion  of  the  disease  of  which  I  am  now  to  speak. 

Polypus  is  indeed  a  dreadful  disease  ;  but  like  every  other,  it 
becomes  so  by  a  slow  progression,  and  advances  by  gradations 
easily  characterised,  and  which  you  will  do  well  to  mark.  It  is 
described  as  a  small  and  pendulous  tumour,  projecting  in  the 
nostril,  void  o.  pain,  attended  with  no  worse  symptoms  than 
watering  of  the  eyes,  and  sneezing,  sometimes  soft,  some- 
times firm  in  its  texture,  and  moving  backwards  and  forwards 
with  the  breath.  You  would  imagine  nothing  more  simple 
than  to  noose  such  a  tumour  with  a  thread,  or  pull  it  away  with 
forceps. 

And  so  indeed  is  every  polypus  in  its  early  stages,  a  small, 
tight,  and  moveable  tumour,  attended  with  sneezing,  watering 
of  the  eyes,  swelling  in  moist  weather,  descending  with  the 
breath,  but  easily  repressed  with  the  point  of  the  finger,  void 
of  pain,  and  in  no  shape  alarming  ;  and  it  is  easily  extracted 
too,  so  as  for  a  time  to  clear  the  passage  for  the  breathing  !  Yet 
this  little  tumour,  simple  as  it  may  appear,  is  the  germ  of  a 
very  fatal  and  Loathsome  dbcase ;  and  this  easy  extraction,  th« 


On  Tumours  of  the  Nostrils,  Gums,  and  Throat.       407 

very  cause,  often,  of  its  appearing  in  its  most  malignant  form  : 
the  more  easily  it  is  extracted,  the  more  easily  dees  it  return  ; 
and  whether  carelessly  extracted,  or  altogether  neglected,  it 
soon  returns  ;  and  when  it  does  return,  it  has  not  in  truth 
changed  its  nature,  it  has  not  ceased  to  be  in  itself  mild  ;  it  is 
then  to  be  feared,  not  from  its  malignity,  but  from  its  pressure 
among  the  delicate  cells  and  membranes  of  the  nose  :  it  soon 
fills  the  nostrils,  and  obstructs  the  breathing,  and  causes  in- 
describable anxieties  :  the  patient  lies  all  night  with  open 
mouth  ;  during  sleep  he  is  harassed  with  fearful  dreams  ;  and 
when  he  wakes  his  mouth  and  throat  are  parched  and  dry. 
The  tears  are  obstructed,  and  the  eyes  become  watery  from  the 
pressure  on  the  lachn  mal  sac  ;  the  hearing  is  in  like  manner  in- 
jured, by  the  pressure  of  the  tumour  against  the  mouths  of  the 
Eustachian  tubes  ;  the  voice  is  changed,  and  its  resonance  and 
tone  entirely  lost,  by  the  sound  no  longer  passing  through  the 
cells  of  the  nose  and  face  ;  the  swallowing  is  in  some  degree 
affected  by  the  tumour  depressing  the  soft  palate  ;  the  pains 
arising  from  such  slow  and  irresistible  pressure  are  unceasing  ; 
from  the  same  pressure  the  bones  become  carious,  and  the  cells 
of  the  face  and  nose  are  burst  up  by  its  slow  growth. 

The  tumour,  in  no  long  period,  begins  to  project  from  the 
nostril  before,  and  at  the  arch  of  the  palate  behind  ;  one  nostril 
grows  wide  and  thick,  the  nose  is  turned  towards  the  opposite 
side,  and  the  whole  face,  in  consequence  of  a  rising  of  the 
cheek-bones,  becomes  oblique  :  the  root  of  the  nose,  where 
it  is  set  off  from  the  forehead,  swells  and  becomes  puffy  ; 
the  features  tumid  and  flabby,  the  face  yellow,  and  the  parts 
round  the  eye,  livid  :  the  patient  is  affected  with  headachs  which 
seem  to  rend  the  bones  asunder,  and  with  perpetual  stupor  and 
dozing  :  the  bones  and  membranes  now  plainly  ulcerate  ;  a 
foul  and  fetid  matter,  blackened  with  blood,  distils  from  the 
nostrils,  and  excoriates  them,  and  by  passing  partlv  clown  the 
throat,  occasions  diarrhoea  :  the  blood-vessels  next  give  way, 
and  sudden  impetuous  haemorrhages  weaken  the  patient  ;  the 
teeth  fall  from  the  sockets,  and  through  the  empty  sockets  a 
foul  and  fetid  matter  issues  from  the  antrum. 

Now  the  disease  verges  towards  its  conclusion.  The  patient, 
conscious  that  the  tumour,  lately  so  mild  and  moveable,  has 
degenerated  into  a  mortal  disease,  is  resigned  to  his  fate  ;  and 
no  flatteries  of  his  friends,  nor  soothing  words  from  his  physi- 
cians, can  longer  deceive  him  :  in  the  night  he  starts  from  his 
sleep,  in  horrible  dreams,  and  with  a  sense  of  suffocation  ;  and 
frequent  haemorrhages  bursting  out  from  time  to  time,  reduce 
him  to  such  extremity  of  weakness,  that  for  several  days  he  is 
not  able  to  crawl  from  his  bed  ;  and  when  he  rises  from  it,  he 


408        On  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

hangs  over  the  fire,  cold  from  loss  of  blood,  pale  as  a  spectre, 
his  lips  colourless,  and  his  lace  like  wax,  yellow  and  transpa- 
rent :  he  hangs  his  head  forwards,  resting  it  on  his  hand,  and 
moving  it  incessantly  from  side  to  side,  from  the  intolerable 
pain,  the  saliva  distilling  from  his  mouth,  and  the  foul  matter 
dropping  from  the  nose  :  in  this  state  he  survives  a  lew  weeks, 
desolate  and  hopeless.  During  the  last  days  of  his  illness,  he 
lies  in  a  state  of  perpetual  stupor,  and  dies  lethargic. 

Never  can  you  thoroughly  know  this  part  of  your  profession, 
nor  arrive  at  a  just  sense  of  the  danger  of  this  disease,  till  you 
have  seen  your  patients  thus  suffering  and  dying;  nor  have  you, 
from  systematic  books  of  surgery,  the  very  slightest  intimation, 
that  scenes  like  these  are  passing  in  the  chambers  of  the  sick. 
Perhaps,  it  will  be  said,  (I  wish  it  could  be  justly  said)  these 
are  very  exaggerated  pictures  !  they  are,  on  the  contrary,  so 
very  faithful  and  true,  that  I,  who  have  witnessed  them  many 
times,  know  hot  how  they  can  be  exaggerated  ;  I  have  traced, 
as  simply  as  I  could  describe,  with  any  regard  to  truth,  the 
phenomena  of  this  disease,  from  the  stage  reputed  harmless 
and  mild,  to  that  reputed  malignant.  If,  indeed,  horrid  symp- 
toms could  establish  the  fact  ol  malignity,  that  there  is  not  to  be 
found  in  all  nosology  a  more  malignant  disease  than  this :  but 
aneurism,  though  it  destroys  the  thigh-bone,  the  sternum,  or 
the  cranium,  is  not  accounted  malignant  ;  neither  is  polypus 
malignant,  though  it  destroys  the  cells  of  the  face,  and  pene- 
trates even  through  the  ethmoid  bone,  to  the  brain. 

I  shall  demonstrably  prove  to  you  that  polvpus  is  a  tumour 
in  itself  indolent  and  harmless  ;  that  it  is  no  farther  malignant 
than  as  it  does,  by  universal  and  irresistible  pressure  in  the  lat- 
ter stages,  destroy  the  bones :  that  circumstances  determine  the 
growth,  and  the  more  or  less  rapid  growth,  determines  the 
fate  of  the  patient :  and  I  shall,  I  doubt  not,  prove  to  your  con- 
viction, that  it  is  far  better  to  suffer  the  salutary  pains  of  ope- 
ration and  caustic,  than  the  unavoidable  tortures  of  a  disease, 
which,  as  soon  as  it  becomes  painful,  is  incurable.  You  are, 
by  every  law,  moral  and  professional,  bound  to  continue  your 
good  offices  to  your  patient,  while  he  consents  to  suffer,  or 
there  remains  the  slightest  hope  of  success.  While  the  doc- 
trine of  benignity  and  malignity  (and  these  terms  are  repeated 
in  every  page  of  Pott  and  other  writers)  is  acknowledged,  while 
the  surgeon  pronounces  every  incipient  polypus  mild  only,  be- 
cause it  is  small,  and  as  yet  harmless  ;  and  every  polypus  ma- 
lignant which  has  attained  a  conspicuous  size  and  more  solid 
texture,  and  begins  to  affect  the  bones  :  while  he  neglects  the 
beginning,  and  shuns  all  concern  in  the  lamentable  conclusion  of 
the  disease,  no  patient's  life  is  safe. 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.         409 

Yet  with  all  these  distinctions  of  mild  from  malignant  polypi, 
and  endless  injunctions  not  to  tamper  with  the  disease,  no  au- 
thor  can  refrain  from  praising  that  operation,  whether  by  liga- 
ture, forceps  or  caustic,  to  which  he  is  most  favourably  inclin- 
ed ;  and  in  such  familiar  terms  are  the  several  stratagems  for 
reaching  the   roots  of  the   tumour  described,  that  I  know  not 
how  the   young   surgeon  can  escape   a  deception  so  naturally 
suited  to  the  complexion  of  an  ardent  and  inexperienced  mind* 
It  is  impossible  to  read  the  boundless  commendations  lavished 
by  each  author  on  his  own   peculiar   operation,  without  being 
persuaded   of  its   efficacy,  and  imagining  besides  a  thousand 
other  ways,  the   least  perfect  of  which  will  equally  succeed  : 
but  there  is  a  sad  disappointment  when  we  put  those  inventions 
to  the  test  of  actual  practice.     Instruments  and   methods  of 
cure  have  been   imagined  in  the  closet,  by  men  who  have  not 
even  introduced  a  finger  into  the  nostril,  much  less  felt  the  in- 
finite'difficulty  of  casting  a  noose  round  a  polypus  ;  and  the  re- 
sult is,  that,  while  these   methods   are  very   seemingly  perfect, 
declared  by  their  inventors  to  be  infallible,  and  allowed  by  all 
to  be  ingenious,  they  are  altogether  unavailing  when  put  to  the 
test.     The  young  surgeon  finds  these  practices  so  described  in 
books,  that  he  thinks  of  nothing  but  the  admirable  ingenious- 
ness  of  the  invention,  nor  can  he   admit  a  doubt,  that  he  can  in- 
troduce his  probes,  his  tubes,  and  his  catgut  or  wires',  so  as  to 
noose  the  tumour  :  but  when  he  goes  to  grapple  with  the  actual 
disease,  and  while  he  is  struggling  to  apply  his  wires,  the  nose 
is  streaming  with  blood,  the  patient  staring  and  struggling  as  if 
in  the  act  of  suffocation,  the  tubes  and  forceps  are  thrust  perse- 
veringly  into  the  nostrils  and  throat,  the  torceps  are   next  dri- 
ven deeper  into  the   nostrils,  the  blood  streams  again,  and  the 
pendulous  p  <rts  of  the  polypi,  which  are  more  prominent  in  the 
nostrils,  are  bruised  and  mangled,  while  their  roots  are  left  en- 
tire, and  only  fragments  of  the  tumour  mixed  with  the  clots  of 
blood,  are  found  upon  the  clothes.     The  patient  terrified,  sick- 
ened, and  spent  with  haemorrhagv,  prays  tor  some  suspense  of 
his  suffering,  at  the  moment   when  the  surgeon  begins  to   be 
abashed  at  his  ill  success  ;  he  desists,  for  awhile,  from  farther 
violence,  but  the  same   unsuccessful   operations   are   repeated 
from  time  to  time,  and  if  but  the   slightest  breath  of  air  pass 
through  the  nostril,  he  takes  advantage  of  that  seeming  success, 
and  introducing  bougies,  or  a  thick  roll  of  lint,  persuades  his 
patient  that  his  condition   will  improve  daily.     But  the  patient, 
after  a  season  spent  in  vain  and  miserable  endeavours  to  pre- 
serve the  nostril  free,  returns  to  town   with  carious  bones,   de- 
formed features,  a  projecting  polypus,  a  frame  exhausted   with 
suffering,  and  especially  cxhausu  1   bv  suffocation    and  want  of 
.1  F 


410        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

sleep  :   his  life  is  threatened  every  moment  by  impetuous   hae- 
morrhagies,  and  he  is  plainly  beyond  the  help  of  better  surgery. 
God  forbid  that  I   should  impute  such  negligence  to  a  de- 
sire of  gain,  or  contempt  of  duiy,  to   a  haste  to  succeed,  or  a 
vain  desire  to  appear  successful.     These  are  the  consequences 
merely  of  a  deception,  which  no  one  who  takes  his  ideas  from 
books  can  well  escape.     The  operation  of  noosing  a  nasalpoly- 
pus,  which  I  shall  prove  to  be  altogether  futile ;  or  that  of  ex- 
tracting it  with  forceps  alone,  which  I  know  by  experience  ne- 
ver can  be  perfect  or  successful,  are  yet  represented  as  perfectly 
effectual.     The  operation  of  noosing  a  polypus  is  one  which  the 
young  surgeon  is  taught  to  perform  with  all  the  ceremonies  and 
circumstances  of  an  operation ;  and  if  it  is  but  so  performed, 
that  the  wire  or  ligature  does  not  immediately  drop  away,  all 
the  instructions  he  has  ever  read  or  heard  of,  seem  to  be  ful- 
filled, though  the  tumour  begins  to  project  again  in  a  few  days. 
He  believes  the  cure  of  polypus  to  be  an  operation  to  ■  hfe  ac- 
complished at  once,  by  a  coup  de  main,  while  in  truth  it  is  a 
cure  to  be  accomplished  by  various  and  persevering  methods. 
The   operation  of  noosing  or  extracting   a  polypus  is  far  from 
being  a  splendid  piece  of  surgery,  fit  to  be  exhibited  in  an  ope- 
ration room.     I   have  never  known   an  operator  put  on  his 
sleeves,  and  address  himself  to  the  work  with  those  mistaken 
notions  ;  and  in  the  hopes  of  visibly  unrooting  the  tumour  with 
the  forceps,  or  entangling  it  in  a  noose,  who  did  not  retire  from 
the  scene  with  confusion  and  dismay.     The  horrid  scene  which 
ensues,  the  quick  re-production  of  the  tumour,  and  the  caries 
of  the  bones,  is  not  the  effect  of  tampering  with  a  malignant 
disease,  but  the  natural  progress  of  a  tumour  uninterrupted  by 
operations  so  imperfect  and  mal-adroit.     Let  no  man  attempt 
the   cure  of  this  disease  whose  sole  purpose   is  to  shine  as  an 
operator  j  who  has  not  perseverance  and  diligence  enough  to 
try,  successively,  every   method,  and  humility  enough  to  be 
contented  with  the   happiness   of  saving  his   patient  by  any 
means. 

I  verily  believe,  that  none  are  more  innocent  than  those  who 
deceive  us  by  commending  such  trivial  operations,  for  they  first 
impose  upon  themselves.  They  invent  an  instrument  or  me- 
thod indisputably  ingenious,  and  with  all  the  simplicity  in  the 
world  imagine,  because  it  is  ingenious,  that  it  must  be  useful. 
I  believe  the  very  reverse  of  this  might  be  proved  by  all  past 
experience,  in  respect  to  surgical  inventions  ;  for  the  most  cu- 
rious and  ingenious  have  invariably  proved  the  most  inefficient; 
and,  if  passing  over  the  first  inventor  and  his  eulogiums,  you 
inquire  of  the  next  who  tried  the  instrument,  you  find  it  quite 
useless  ;  or,  if  one  have  performed  the  operation,  and  it  be  left 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.        41 1 

lo  another  to  report  its  success,  the  reverse  is  sudden  and  mor- 
tifying. Speaking  on  this  subject,  I  cannot  help  laying  before 
you  one  example  ol  this,  to  me  the  more  striking,  as  I  remem- 
ber how  much  I  was  delighted  when  a  boy,  with  the  piece  of 
mechanical  ingenuity  which  I  am  now  going  to  explain  :  so 
much  was  I  delighted,  that  in  my  admiration  of  the  author's 
genius  I  contrived  to  forget  his  ill  success.  The  operation  is 
related  in  the  third  volume  of  the  Edinburgh  Essays,  Physical 
and  Literary.  '*  A  man  of  the  name  of  Davison,  very  far  ad- 
vanced in  years,  was  admitted  into  the  Royal  Infirmary,  with 
a  voluminous  polypus,  which  had  its  root  near  the  epiglottis, 
lay  within  the  oesophagus,  and  was  occasionally  vomited  up, 
when  he  was  excited  by  emetics,  or  by  thrusting  the  finger  into 
the  fauces.  The  polypus  then  occupied  the  mouth,  extended 
to  the  fore-teeth,  and  appeared  to  consist  of  four  distinct  lobes, 
arising  from  one  root  or  neck.  But  the  polypus,  while  it  thus 
occupied  the  mouth,  prevented  the  breathing  of  the  patient,  by 
covering  the  opening  of  the  trachea  ;  wherefore,  having  just 
shewn  it  to  his  surgeons,  by  vomiting  it  up  into  the  mouth,  he 
was  obliged  presently  to  swallow  it  down  again  for  want  of 
breath.  His  speech,  his  swallowing,  and  his  breathing,  were 
all  so  affected  by  this  very  voluminous  tumour,  that  it  became  a 
very  interesting  question  how  to  extirpate  the  tumour  :  and  it 
was  proposed,  that  while  the  operation  of  bronchotomy  was 
performed  to  give  him  breath,  the  noose,  by  the  help  of  some 
very  ingenious  useless  machines  should  be  cast  over  the  tu- 
mour, which  latter  part  of  the  scheme  was  fulfilled  in  the  fol- 
lowing manner  :  a  ring,  mounted  on  a  stalk,  and  having  the 
thread  designed  for  ligature  concealed  within  the  circle  of  the 
ring,  was  pushed  down  into  the  fauces  :  the  pushing  down  of 
the  ring  excited  the  patient  to  vomit,  and  the  ring  so  occupied 
the  fauces,  that  when  the  tumour  was  vomited  up  it  was  driven 
through  the  ring  ;  the  ring  was  then  pushed  harder  down  to- 
wards the  root  of  the  tumour  ;  the  ligature  was  then  drawn 
tight  ;  other  instruments  with  wheels  and  pulleys  for  passing  a 
double  ligature  (the  single  one  not  succeeding)  were  next  in- 
vented ;  and  finally,  the  purpose  was  so  effectually  accomplish- 
ed, that  the  polypus  was  strangled  :  he  passed,  by  stool,  lumps 
which  be  mistook  for  clots  of  blood  ;  but  he  passed  also  along 
with  those,  the  loop  of  the  ligature  with  which  the  polypus 
was  noosed.'1  It  is,  in  short,  insinuated  in  the  surgeon's  nar- 
rative, that  the  patient  had  passed  the  bulk  of  the  polypus  by 
stool  ;  and  it  is  directly  affirmed,  (by  Mr.  Dallas,  the  operator) 
that  "  having,  at  the  end  of  the  month,  sent  for  the  patient  and 
examined  his  throat,  and  made  him  vomit,  nothing  preterna- 
tural appeared  ;  and  that,  having  presented  himself  at  the 


412        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

tance  of  eight  months  at  the  infirmary,  on  account  of  a  com- 
mon cold  with  which  he  had  been  lately  seized,  he,  upon  being 
examined,  seemed  to  be  entirely  free  from  any  ailments  of  the 
polypous  kind.'''' 

Such,  and  so  circumstantial  is  the  narrative  of  this  ingenious 
invention,  and  of  its  success  ;  and  it  is  supported  by  all  the 
usual  apparatus  of  names,  dates,  consulting  surgeons,  opera- 
tion-room, students,  &c.  Hear  now  how  a  plain  tale  puts  this 
down  ;  hearken  to  the  fate  of  a  poor  soul  (in  the  month  of 
April,  1765)  who  was  declared  thus  entirely  free  in  April  1764 
u  of  all  ailments  of  the  polypous  kind."  u  I  was  informed," 
says  Dr.  Monro,  "  that  James  Davison  had  died  in  the  Royal 
Infirmary,  to  which  he  had  returned  a  few  weeks  before  that, 
very  feeble  and  emaciated,  as  for  several  months  past  he  had  not 
been  able  to  swallow  any  solid  food,  and  even  swallowed  fluids 
with  much  difficulty  ;  the  polypus  had  not  however  been  seen 
by  the  surgeons  who  had  examined  his  throat. 

M  On  dissecting  his  body,  the  oesophagus  was  found  to  be 
greatly  dilated,  by  a  very  large  fleshy  excrescence  or  polypus, 
which  grew  out  from  its  fore-part,  by  a  single  root,  about  three 
inches  lower  than  the  glottis,  but  was  split  at  its  under  part  into 
several  lubes,  the  largest  and  longest  of  which  reached  down  to 
the  upper  orifice  of  the  stomach."  So  untrue  is  the  tale  told 
by  a  man  who  never  designed  to  deceive  !  Judge,  then,  how 
dangerous  it  is  to  believe,  where  there  is  no  other  evidence  than 
that  of  the  inventor,  and  where  the  cunning  of  the  mechanism 
is  so  apt  to  pass  for  a  demonstration  that  it  must  be  successful. 
Believe  me  it  is  safer  to  doubt  ;  it  will  be  found  by  all  past  ex- 
perience, that  the  most  ingenious  and  complicated  schemes  are 
apt  to  fail  in  exact  proportion  to  the  seeming  ingenuity  of  the 
invention.  I  can  venture,  on  my  own  authority,  to  assure 
you,  that  the  ring  of  Hildanus,  the  tubes  of  Levret,  the  probes 
and  other  instruments  by  which,  as  later  authors  assure  you,  it 
is  so  easy  to  apply  the  noose,  and  slip  it  up  to  the  very  root  or 
pedicle  by  which  the  polypus  hangs  ;  the  very  instruments  and 
methods  which  you  have  taken  most  delight  in  practising,  will 
fail  you. 

I  am  now  to  enter  upon  the  anatomical  investigation  of  this 
subject,  and  to  speak  of  the  origin,  form,  and  effects  of  poly- 
pus ;  a  subject  which  will  admit  of  no  conjecture  ;  of  the  man- 
ner in  which  the  tumour  presents  itself  in  the  passages  of  the 
nostrils  and  throat ;  and  how  it  may  be  successfully  grappled 
with,  a  subject  surely  of  the  highest  importance  to  the  practical 
surgeon. 

I  affect  not  to  purge  the  science  of  every  prejudice,  Jout  those 
which  have  a  direct  relation  to  our  subject   in  any  practica- 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.         413 

sense,  I  like  to  treat  of  freely.     That  a  small  and  apparently 
trivial  tumour  of  the  nostril  should  be  ascribed  to  the  common 
and   unseemly  practice  of  picking  the  nose,  is  far  from  being 
particular  ;  and  were  this  reported  merely  to  frighten  bojsfrom 
unseemly  practices,  I   should  leel  little  disposed  to  refute   it. 
But  there  is  a  most  dangerous  prejudice  connected  with  this  er- 
ror, viz.  that  the  polypus  is  not  only  tangible,  but  its   root  ac- 
cessible to  the  finger,  since  caused  by  the  intrusion  of  it.     The 
most  impatient  finger  could  never  reach  that  part  of  the  nostril 
where  polypus  has  its  seat,  for  that  is  deep  and  high  in  the  nos- 
trils, towards  the  throat,  and  near  the  openings  of  the  Eustachian 
tubes.     The  finger  can  be  admitted  no  deeper  than  the  cartila- 
ginous wing  of  the  nose  extends,   and  can  hardly  touch  the 
anterior  point  of  the   lower  spongy  bone.     The  anterior  and 
posterior  chambers  of  the  nostril  are  separated  from  each  other 
by  a  narrow  slit,  which  the  finger  can  never  pass  ;  this  opening 
is  somewhat  of  the   carved  form  of  the  slit   in  the  sounding- 
board  of  a  violin,  and  the  intrusion  of  the  anterior  point  of  the 
spongy  bone,  which  is  the  point  that  encounters  the  finger  when 
thrust  into  the  nostril,  gives  it  this  peculiar  shape.     There  is  a 
little  opening  above,  and  another  below  this  projecting  point  of 
the  spongy  bone  ;  through  these  the  heads  ol  the  polypus  pro- 
ject; one   generally  fills  the   opening   above  the  spongy  bone, 
another  polypus  usually  fills  the  space  below ;  there  they  hang 
pendulous,  and  are  forced  sometimes  through  this  opening  by 
the  breath  pushing  them  down  very  low  ;  at  other  times  they 
are  retracted   by  drawing  in  the  breath  ;  but  how  very  distant 
this  tangible  part  of  the  polypus  is  from  its  root,  and  how  long 
the  tumour  usually  is,  I  shall  next  prove  to  you.     The  very 
proof  of  this  is  dissection  ;  and  if  what  I  have    described  be 
true,  you  will  find  it  obvious  in  the  drawings,  to  which  I  next 
appeal:  in  these   you  will  observe,  that  all  the  polypi  are  long 
and  pendulous,  and  only  bulbous   at  the  extremity  where  they 
are  felt  with  the  finger.     You  will  observe,  that  in  const  quence 
of  their  great  length,  the  roots  are  at  a  great  distance  from  the 
pedicle  or  stalk,  from  which  they  grow,  that  their  bulbous  ex- 
tremity cannot  be  felt  at  all  times,  their  roots  never,  for  they 
are  in  the  highest  and  narrowest  part  of  the  nostril.     You  will 
observe,  that  polypi,  which,  were  they  produced  by  picking  the 
nose,  or  any  local  injury,  would  be  solitary,  are,  on   the  con- 
trary, numerous  beyond  any  conception  you  can  have  formed*". 

*  It  is  by  no  means  a  matter  of  flight  importance  to  afcertain  this  point.  Wo 
know  by  diffection,  and  by  much  fad  experience,  that  polypi  are  rarely  folitary  ; 
that  the  whole  membrane  is  diseased,  that  both  noftrils  are  frequently  affected; 
that  the  cells  as  well  as  the  paffages  of  the  nose  and  throat  are  ftudded  with  polypi 
of  various  fizes.     The  melancholy  cafe  which  I  am  now  to  tranfcribe,or  rather  to 


414        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

Polypi  hang  forwards  in  the  nose,  in  a  direction  so  unfavour- 
able to  their  being  noosed,  that  I  see  it,  from  the  preparation, 

plan  xo.   1. 


epitomife,  from  one  of  the  most  celebrated  writers  on  this  diforJcr,  is  a  proof 
how  rarely  it  is  local,  how  impoffible  that  it  fhould  be  produced  by  picking  the 
Jiofe,  or  any  fuch  injury,  how  univerfaUy  the  membrane  is  d.fcafed. 

"  A  young  man,"  fays   Manr.c,  "  of  twenty-feven    years  of  age,    died  at  La 
Charit€.      Three  years  after    having  the  fmall   pox,  from  which  period  he  bad 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.       415 

as  improbable,  as  I  have  felt  it  in  practice  impossible  for  the 
young  surgeon  to  succeed  in  noosing  them ;  and  a  practical 
fact  is  the  point  to  which  I  shall  particularly  call  your  attention  ; 
yet  let  me  acknowledge,  that  it  is  by  experience  alone  that  I 
have  learned  how  difficult  it  is  to  noose  that  lesser  polvpus 
which  hangs  forward  in  the  nose.  Had  I  sat  down,  like  many 
of  my  betters,  in  the  closet,  to  contrive  ways  of  noosing  such 
a  tumour,  I  could  have  imagined  nothing  more  likely  to  suc- 
ceed than  the  common  process.  I  no  more  doubted  than  others, 
that  the  method  which  I  found  so  ingenious,  when  described  in 
books,  could  fail  me  in  the  act.  Allow  me  to  explain,  first  the 
Plan  No.  1,  from  which  you  will  learn  the  actual  circum- 
stances of  these  kind  of  tumours.  Secondly,  The  plan,  No.  2, 
which  will  illustrate  this  indescribable  and  unforeseen  difficulty 
of  noosing  them.  In  this  plan  1,  fig.  1,  you  cannot  but  remark, 
that  the  three  polypi,  with  which  the  nostril  is  filled,  the  largest 
marked  (a),  the  next  in  size,  (bj,  and  the  third,  fcj,  hang 
from  a  point  very  high  in  the  nostril,  and  very  far  back,  that 
their  roots  must  be  in  the  posterior  end  of  the  upper  spongy 
bone,  under  the  socket  of  the  eye,  and  not  far  from  the  open- 
ing of  the  Eustachian  tube.  Of  this  you  will  be  satisfied  by 
looking  to  Fig.  2,  taken  from  the  same  preparation,  hanging 
still  by  the  same  thread,  only  turned  round,  so  as  to  shew  the 

been  affli&ed  with  polypi  in  the  nofe  ;  a  whole  hot-bed  of  them  (fays  the  author), 
if  I  may  be  permitted  to  ufe  the  term,  appeared.  He  had  in  the  paffages  of  the 
throat  and  nofe,  in  the  antrum  maxillurc  of  each  fide,  and  in  the  frontal  finufes 
seven  polypi  in  all.  His  face  was  (hockingly  deformed ;  he  had  a  great  bulging 
at  the  root  of  the  nofe  ;  his  eyes  were  removed  from  each  other,  by  the  fwelling, 
to  three  times  their  natural  diftance,  and  feemed  burfting  from  their  fockets  ;  the 
noftrils  were  expanded,  and  the  nofe  flattened  and  extended ;  while  the  cheek 
bones  were  raifed  to  the  level  of  the  nofe,  and  the  face  and  head  fwelled  to  an 
enormous  fize.  The  ears  were  obftruct.ed  on  either  Ode  ;  the  tears  flowed  over  the 
excoriated  cheeks,  and  fomctimes  fetid  pus  burft  out  from  the  fiftula  lachrymalis  on 
either  fide. 

"  While  his  head  and  face  were  thus  externally  deformed,  the  palate  of  this 
mifcra"blc  creature  was  fo  depreffed  that  it  lay  upon  the  tongue,  and  bulged  fo,  that 
the  lower  jaw  wasdeprefled  ;  the  mouth  kept  perpetually  gaping,  fothat  the  faliva 
diflilled  continually  from  his  jaws,  while  the  r.oftrils  were  diftended  by  the  bulbous 
extremities  of  two  larger  polypi. 

'•  In  diflecting  his  head  thefe  polypi  were  found  to  have  occafioned  great  de- 
valuation ;  the  cheek  was  laid  open  by  a  crucial  incilion,  and  the  upper  maxillary 
bone  fcemingly  annihilated,  nothing  being  left  of  the  walls  of  the  antrum  but  a 
thin  fcale  like  the  peeling  of  an  onion  :  on  opening  the  oppofite  cheek  they  found 
the  antrum  buril  open  in  a  ftar-like  form,  and  on  dividing  the  delicate  membrane 
which  clofed  this  breach  in  the  antrum,  a  thin  and  bloody  ferum  exuded,  and 
there  projected  from  the  cavity  a  fmall  portion  of  a  very  firm  and  elaftic  polypus 
of  a  red  colour  ;  and  when,  by  cutting  and  tearing  away  the  reft  of  the  bone,  the 
tumour  was  found  very  large  and  quite  infulated,  except  at  its  neck,  which  wa<= 
of  fuch  dimenfions  as  to  be  eafily  embraced  in  the  circle  of  the  fore- linger  and 
thumb.  It  refembled  a  turnip  in  refpect  of  fhape  ;  its  lower  end  was  bulbous  and 
large  ;  but  its  pedicle,  or  immediate  attachment,  was  so  exceeding!;  delicate  that 
it  leemed  difficult  to  imagiue  how  fo  great  a  tumour  could  grow,  or  even  he  nou- 
rifhed,  when  formed,  by  fo  fmall  a  rest.      It  *:.■>' no  more  than  one  line 


416        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

back  of  the  nostrils;  and  here  the  same  iron  probe  (d)  is  left 
in  the  nostril.  You  may  see  how  this  nostril  (the  right  one)  is 
dilated  by  the  polvpi.  The  septum  or  partition  of  the  nostril 
(ej  is  inclined,  by  the  pressure,  towards  the  left.  The  poste- 
rior opening  of  that  nostril  into  tht  throat,  marked  (fj,  is  great- 
ly dilated ;  nor  must  you  wonder  at  this,  for  the  tumour  was 
once  large  and  bulky.  Tumours  which,  in  the  dead  body,  are 
flat,  long,  and  corrugated,  by  long  immersion  in  spirits,  may 
not  only  have  filled,  but  distended  the  nostril,  and  dilated  it 
permanently  :  (g)  marks  the  centre  of  the  septum  greatly  in- 
clined to  the  left,  and  (h )  marks  the  mouth  or  opening  of  the 
Eustachian  tube  ;  the  tumours  taking  their  origin  betwixt  this 
and  the  nostril,  marks  the  point  of  their  origin  to  be  the  upper 
spongv  bone  ;  and  the  patient  suffering  deafness  from  the  pres- 
sure of  the  polypus  against  this  opening,  shows,  that  slender 
as  the  tumour  appears  in  this  preparation,  they  had,  when  the 
patient  was  active,  and  the  blood  in  full  circulation,  been  suffi- 
ciently bulbous  to  occupy  the  whole  circle  of  the  opening,  (i)  : 
(k  kj  marks  the  whole  length  of  that  slit-like  opening,  betwixt 
the  septum  and  spongy  bones,  which  the  finger  can  never  pass, 
and  which,  from  its  narrowness,  occasions  the  chief  difficulty 
in  managing  instruments  of  any  kind,  and  especially  those  tubes 

twelfth  of  an  inch)  in  diameter,  and  of  the  fame  length.  The  coat  of  the  tu- 
mour was  fmooth,  delicate,  not  irregular  nor  warty  ;  its  fubftance  was  lardy,  and 
the  bottom  of  the  cavity  in  which  it  was  lodged  formed  one  half  of  that  concavity 
of  the  palate  which  preffed  upon  the  tongue.  On  opening  the  antrum  of  the  op- 
pofite  lide,  they  found  it  occupied  with  a  tumour  exprefsly  fimilar  in  all  points 
and  circumftances,  in  fize,  form,  confidence,  and  colour,  and  in  its  effect  upon  the 
adjacent  parts.  Upon  opening  the  two  frontal  finufes  there  was  found  on  each  of 
them  a  tumour  of  half  the  fize  of  thofe  which  diftended  the  antrum.  Thele  alfo 
had  each  its  delicate  pedicle,  which  grew  from  the  margin  of  that  little  hole  by 
which  the  frontal  finus  of  each  fide  communicates  with  the  nofe  ;  the  partition 
betwixt  the  finufes  was  deftroyed,  thence  they  formed  but  one  general  cavity ; 
from  this  cavity,  as  from  the  antra  Highmoriana,  a  little  of  a  yellowifh  ferum  if- 
fued,  upon  their  being  opened ;  and  here,  as  in  the  antrum,  the  pituitary  or 
Schneiderian  membrane  was  much  thickened.  Thefe  tumours  were  fpherical, 
but  the  mutual  preffure  of  the  tumours  had  flatttened  each  upon  that  fide  when  it 
encountered  its  fellow.  To  have  a  more  perfect  view  of  the  effects  of  this  pref- 
fure on  the  adjacent  parts,  they  were  obliged  to  diffect  out  the  eyes,  and  then  it 
was  feen  that  the  eyes  were  dilplaccd  by  the  preffure  of  thefe  tumours  which  had 
made  the  inner  fide  of  each  orbit  bulge  outwards;  and  upon  opening  the  f'cull 
they  found  that  a  thin  protuberance  had  actually  compreffed  the  brain,  for  fhc 
two  hollows  of  the  os  frontis  were  convex  and  preffed  fo  inwards,  that  betwixt 
them  the  crifta  galli  was  entirely  concealed.  Upon  opening  the  throat  behind  the 
palate,  three  tumours,  feemingly  arifing  fro'  one  pedicle,  were  feen  projecting 
into  the  fauces. 

"  This  may  ferve  as  a  general  analyfis  of  this  unhappy  cafe,  and  mull  fuggeft 
a  doubt  whether  it  may  not,  in  circumftances,  be  allowable  and  laudable  to  at- 
tempt the  defperate,  ye6  harmkfs  operation  of  trepaning,  or  rather  cutting  open, 
with  a  ftrong  fcalpel,  the  frontal  or  maxillary  finufes,  diftended,  foftened,  and  be- 
come carious  by  the  long  preffure  of  fuch  enormous  tumours.  It  is  lamentable  t» 
obferve  how  unavailing  every  kind  of  operation  muft  be  where  the  tumours 
are  thus  numerous,  and  in  how  fhort  a  period  it  runs  its  fatal  courfe," 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.         417 

and  probes  which  I  am  next  to  describe.  But  while  I  am  mak- 
ing these  observations  on  the  drawing,  you  cannot  but  remark 
the  proof  of  those  peculiarities  I  have  already  taken  notice  of, 
viz.  that  polypus  is  not  solitary  ;  on  the  contrary,  that  the  pre- 
disposition is  so  strong,  that  three  or  four  polypi  are  often 
crowded  in  one  nostril,  a  circumstance  extremelv  unfavourable 
to  the  operation  of  the  ligature,  which,  though  in  itself  effectual, 
would,  in  a  case  like  this,  fail ;  for  it  would,  in  such  a  case,  re- 
quire to  be  applied  three  successive  times;  after  each  operation 
the  breathing  would  be  again  interrupted  ;  a  tumour  lying  deep- 
er would  re-place  that  which  was  extirpated,  which  would  thence 
seem  to  grow  again  in  a  few  days  ;  for  one  tumour  only  is  seen 
at  once  ;  a  second  presents  itself  as  soon  as  the  nostril  is  cleared 
of  the  first  :  tumour  after  tumour  presents  in  succession,  and  the 
operations  seem  endless  and  quite  ineffectual.  Besides,  while  the 
polypi  are  numerous  in  one  nostril,  it  rarely  happens  that  others 
are  not  formed  or  forming  in  the  other,  which  are  also  nume- 
rous. Polypi  are  usually  found  at  the  same  moment  fit  for  ope- 
ration in  both  the  nostrils,  as  appears  in  the  right  nostril  of  this 
preparation,  where  (k  k)  represents  a  polypus  long  and  flat, 
resembling  one  of  the  nymphse  in  shape,  and  hanging  from  the 
upper  spongy  bone^/J  ;  lor  in  this  preparation  (vi)  marks  the 
roof  or  upper  part  of  the  antrum  Highmorianum  opened,  that 
part  which  forms  the  floor  for  the  eye  ;  the  alveolar  process  and 
teeth  of  the  upper  jaw  are  cut  away,  and  of  course  the  lower 
spongy  bone  is  gone,  and  only  the  superior  one  (I)  left.  In 
this  drawing,  then,  the  length  of  the  polypi,  their  slender  stalks 
and  bulbous  heads,  their  peculiar  direction,  viz.  hanging  for- 
ward in  the  nostril,  the  straightened  condition  of  the  neck  of 
the  tumour,  and  especially  the  number  of  long  stringy  polypi 
occupying  both  nostrils,  are  circumstances,  I  doubt  not,  alto- 
gether new  and  unexpected.  Now,  you  will  judge,  without 
any  help  of  mine,  how  unlikely  it  is  that  picking  the  nose  should 
ever  cause  this  disease.  The  most  impatient  finger  (I  have 
said)  can  never  (in  picking  the  nose)  reach  that  point  whence 
these  tumours  have  their  origin,  nor  the  most  dexterous  opera- 
tor push  his  finger  so  deep  as  to  reach  these  roots.  You  will 
also  judge  how  impossible  it  is  that  operations  should  be  suc- 
cessfully performed  only  on  that  bulbous  part  of  the  polypus 
which  can  be  touched  with  the  point  of  the  finger  ;  how  difficult 
to  apply  a  noose  to  the  root  of  the  tumour  which  lies  so  lar  be- 
yond the  narrow  slit  of  the  internal  nostril.  Remember,  that 
in  all  your  operations,  and  especially  in  the  application  ol  caus- 
tic to  the  roots  of  polypi  extirpated  by  other  means,  your  aim 
must  be  to  reach  a  point  nearly  under  the  socket  ot  the  eye,  in 
the  deepest  and  highest  part  of  the  arch  of  the  nostrils,  where 

3   (.• 


418 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 


the  nostr'd  opens  backward  into  the  throat.  Remember  the 
length  of  i  polvpus,  (a  circumstance  which  shall  be  demonstrat- 
ed bv  other  drawings)  and  that  however  low  the  bulbous  part 
mav  descend,  or  be  ft  It  bv  the  finger,  it  is  only  by  pushing 
your  instruments  deep,  bevond  the  narrow  cleft  formed  by  the 
projection  of  the  spongy  bone,  that  you  can  do  good. 

plan  no.  2. 


Fiff.2~ 


Let  me  next  represent  to  you,  in  explaining  the  plan  No.  2. 
what  I  conceive  to  be  the  chief  difficulty  in  applying  the  noose 
to  such  tumours:  the  tube  Fig.  (1),  was  invented  by  Mr.  Lev- 
ret,  for  the  purpose  of  passing  a  silver  wire  as  a  noose,  and  of 
tightening  the  noose  after  being  thus  applied  ;  and  in  the  appli- 
cation of  the  ligature,  which  was  new,  and  peculiar  to  Levret, 
he  had  no  motive  so  much  at  heart  as  the  guarding  against  hae- 
morrhagy.  This  was  a  vain  fear,  for  though  I  have  seen  dread- 
ful haemorrhagies  in  the  last  stage  of  polypus,  I  have  never,  in 
twitching  away  polvpi  with  the  forceps,  seen  a  hasmorrhagy 
worth  regarding  ;  I  have  always  kept  a  ligature  in  the  nostrils, 
and  a  plug  in  the  mouth,  ready  to  be  drawn  up,  by  the  help  of 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.        419 

that  ligature,  into  the  posterior  opening  of  the  nostrils,  but  have 
not  found  occasion  actually  to  draw  up  the  plug  more  than  three 
or  tour  times  in  my  life ;  and  then  rather  from  fear  than  dan- 
ger.      The  tube  of  Levret   is   thus  used,  the  loop  of  the  wire 
(uj  is  passed  over  the  lower  end  or  bulbous  head  of  the  poly- 
pus, and  hitched  higher,  towards  the  root  of  the  tumour,  by 
pushing  the  tube  deeper  and  higher  into  the  nostrils,  or   others 
(1  know  not  who,  for  such  probes  are  drawn  in  every  book)  ad- 
vise us,  after  laying  a  noose  of  wire  or  cat-gut  loosely  about  the 
tumour,  to  hitch  it  up  to  the  root,  where  the  tumour  rises  from 
tlu  bone,  by  pushing  it  higher,  first  on  one  side,  then  on  the 
other,  by  the  help  of  the  forked  probe.  Fig.  2.      But  when  you 
look   to  the  scheme  or  imaginary  pi  m  of  such  an  operation,  fi- 
gure  3,   you  will  foresee  mucb  difficulty  in  accomplishing  it ; 
tor   the   tumour,   long  and   slender  as  it  always  is,  hangs  in  the 
direction  in  which  you  are  to  push  the  ligature  ;  the  ligature  or 
noose,  you  never  entertain  a  doubt,  is  to  run  as  clean  and  easi- 
ly along  the  polypus  as  a  ring  slips  upon  the  finger,  or  as  the 
ring  ot   a  window-curtain   slides  along  the  cord  !   but  the  truth 
is,  that  either  from  the  pohpus  being  forced  backwards  into  the 
nostril  along  the   ligature,  or   by  the  hitching  of  some  part  of 
the  noose  against  the  inequalities  of  the   polypus,  or  by  the  nar- 
rowness of  the  nasal  cleft  catching  the   wire,  it  certainly  is  not 
merely  difficult  to  apply  it,  but  impossible.     I  have  seen  such 
an  operation  attempted  filty  times,  by   men  ot  various  degrees 
of  skill,  and  ingenuity,  some  extremely  awkward,  some  pertectly 
dexterous,  but  never  have  I  seen  this  method  succeed  :   if  even 
the  ligature  hung  two  days  by  the  polypus,  still  the  extirpation 
was  but  partial ;   usually  the    ligature  gets  no  hold  on  long  and 
slender  polypi,  which  hang  thus  forwards  in  the  nostril.      No- 
thing, gentlemen,  could  tempt  me,  in  a  question  where  I  am  to 
deliver,  not  an  opinion,  but  a  plain  fact,   to   prevaricate   or  dis- 
guise the  truth,  however  unfavourable  to  myself;  I  have  no 
curious  nor  cunning  operation  to  substitute  in  place  of    that 
which  I  condemn;  but  I  solemnly  and  impartially  declare,  that 
with  my  b,  st  and  most  sincere  endeavours  to  succeed,  I  have 
always    miscarried    in  attempting  to  catch  a  nasal  poK  pus  in  a 
noose  of  wire  or  cat-gut ;   I  have  planned  my  little  operations 
so  cunningly,  that  I  have  imagined  it   impossible  I  should  fail, 
yet,  in  mv  best  concerted  schemes  I  have  been  foiled  as  com- 
pletely as   the  most  awkward  person    1   ever  saw  attempt  the 
operation.       I     hall   ever  therefore  retain  a  suspicion,  that  the 
m  thod  itself,  rather  than  any  want  ^X  address  on  my  part,  is  to 
biame. 

If  I  am  correct  in  ascribing  this  difficulty  to  the  direction  in 
which  the  nasal  polypus  hangs,  being  tho  same   with  that  in 


420        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

which  the  ligature  must  be  drawn,  my  reasoning  will  be  con- 
firmed, by  the  converse  of  the  proposition  being  true,  viz.  that 
guttural  polypi,  those  which,  in  place  of  occupying  the  nostrils, 
pass  backwards  into  the  throat,  are  easily  noosed.  This  is  an 
operation  to  the  happy  success  of  which  I  can  speak  with  con- 
fidence as  perfect,  as  my  conviction  is,  that  the  operation  just 
described  never  can  succeed,  or  very  rarely.  When  the  poly- 
pus is  single,  or  when  one  polypus  has  arrived  at  such  a  size,  as 
to  render  whatever  others  may  be  behind  it  trivial;  when  the 
tumour,  after  having  long  filled  the  nostril,  projects  from  the 
posterior  opening  of  the  nostril  into  the  fauces,  depresses  the 
palate,  hinders  the  swallowing  as  well  as  the  breathing,  and  is 
both  seen,  upon  depressing  the  tongue,  and  felt  upon  passing 
the  fingers  deep  into  the  throat,  firm,  hard,  and  bulkv  :  at  this 
stage  of  its  growth,  when  the  surgeon  most  fears  to  grapple 
with  such  a  tumour,  it  is  in  truth  the  most  manageable,  it  may 
be  extracted  with  safety  ;  its  root  may  be  cut  across  by  passing 
a  curved  knife  along  the  nostril,  yet  not  without  difficulty ;  and 
if  there  be  an  internal  tumour  which  admits  of  extirpation  by 
ligature,  this  is  it.  It  is  the  only  case  in  which  I  can  with  per- 
fect confidence  promise  to  apply  the  noose,  and  where  the  tu- 
mour is  thus  visible  in  the  fauces,  the  ligature  must  be  passed 
through  the  corresponding  nostril,  hooked  out  from  the  fauces 
with  a  hook,  or  catched  with  the  forceps,  brought  through  the 
mouth  beyond  the  teeth  and  lips,  spread  out  upon  the  fingers, 
and  by  the  help  of  the  fingers  (pushed  deep  into  the  throat) 
passed  over  the  bulbous  part  of  the  tumour,  and  then  the  wire 
being  pulled  back  through  the  nostril,  it  slides  up  to  the  root  of 
the  polypus,  or  near  it,  or  may  be  placed  pretty  correctly  by  a 
little  help.  Now  when  thus  drawn,  the  course  of  the  ligature 
is  transverse  to  the  direction  of  the  tumour,  and  is  perfectly 
effectual  in  its  operation ;  for  the  good  effects  of  a  ligature, 
thus  applied,  I  would  willingly  be  responsible,  having  so  very 
often  performed  it  with  unvaried  success.  The  plan  No.  3. 
represents  such  a  guttural  polypus  (a),  small  in  its  neck,  very 
bulbous  in  its  extremity,  bulky  and  solid,  so  as  to  depress  the 
palate,  and  so  wedged  in  the  upper  part  of  the  fauces,  betwixt 
the  fore-part  of  the  vertebra,  and  the  bones  of  the  face,  as  to 
cause  almost  total  deafness,  by  pressing  the  mouths  of  the 
Eustachian  tubes,  and  so  exposed  to  the  operation  of  ligature, 
that  having  passed  it,  you  might,  in  place  of  gradually  twisting 
and  tightening  the  wire,  by  the  help  of  the  tube  (b),  twitch  out 
the  polypus  by  the  roots,  by  mere  force. 

Experience,  if  ever  you  should  be  so  unfortunate  as  to  have 
experience  in  this  disease,  will  best  refute  the  prejudice  so  long 
indulged,  so  often  mentioned  as  an  apology  for  ill  success,  viz. 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.        421 


2H1  3. 


0 


the  malignant  nature  of  some  polypi!  If  hsemorrhagies,  pains, 
or  a  fetid  ichor  distilling  from  the  nostril,  are  to  be  accounted 
tokens  of  malignity,  every  polypus  must  be  malignant  in  its 
latter  stage,  for  its  first  ill  symptoms  begin  from  the  pressure  of 
the  tumour  against  all  the  cells  and  spongy  bones,  and  especially 
the  walls  of  the  antrum  Highmorianum ;  and  its  fatal  conclu- 
sion proceeds  from  a  total  caries  of  the  face.  In  all  the  prepa- 
rations from  which  these  drawings  are  taken,  the  proximity  of 
the  tumour  to  the  antrum  Highmorianum,  or  great  cavity  in  the 
upper  jaw-bone,  is  observable.  In  the  drawing  of  polypus, 
No.  2.  where  the  incipient  polypus  is  seen  hanging  Hap-like  over 
an  edge  of  bone,  that  edge  is  distinguished  to  be  the  partition 
or  thin  plate  of  bone,  which  separates  the  antrum  from  the  nos- 
tril. In  the  drawing  of  polypus,  No.  4.  where  the  small  inci- 
pient polypi  (a  a)  are  seen  one  in  each  nostril,  the  posterior 
openings  of  the  nostrils  (b  b)  are  already  almost  filled  with  these 
tumours,  small  as  they  are.  The  great  cavity  of  the  antrum  is 
marked  on  the  left  side  (e)  ;  there  it  is  cut  entirely  open.  On 
the  right  side,  though  the  bone  is  cut  away,  it  happens  by 
chance,  that  the  very  delicate  membrane,  or  periosteum,  which 
lines  this  cavity,  is  still  almost  entire,  and  you  see  into  the 
antrum  only  by  two  small  irregular  breaches,  (f  g)  in  this  deli- 
cate membrane.  Thus  explained,  this  little  preparation  seems 
to  me  of  the  highest  importance  to  you,  as  giving  you  a  clear 
and  perfect:  conception  of  die  c-iginal  condition  and  final  con- 


422        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat, 

sequences  of  tumours  so  situated;  where  the  most  simple, 
destroying  the  bones  by  their  pressure,  must  in  the  tndseem  ma- 
lignant ;  for  the  bony  parts  and  cells,  as  they  stand  related  to 
such  tumours,  may  be  reckoned  thus:  first  the  septum  narium(h), 
or  partition  which  divides  the  nostrils  all  the  way  from  their 
openings  before  to  that  point  where  each  communicates  at  (b  b) 
with  the  back  of  the  throat.  Secondly,  the  sides  of  the  nos- 
trils (h  h),  which  though  seemingly  very  firm  and  solid  in  this 
drawing,  because  the  jaws  in  this  preparation  are  cut  far  back, 
are  really  very  thin,  especially  in  the  middle  of  the  nostrils,  at 
that  part  where  the  lower  spongy  bone  lies  upon  the  side  of  the 
nose  :  this  plate  of  bone,  as  you  perceive,  divides  the  cavity  of 
the  antrum  Highmorianum  (e  f  g)  of  each  side  from  the  cavity 
of  the  corresponding  nostril ;  it  is  in  short  the  partition  of  the 
antrum,  dividing  that  cavity  from  the  nostril ;  it  is  a  plate  of 
bone,  actually  as  delicate  as  the  os  unguis  ;  covered  with  deli- 
cate membranes,  and  very  easily  destroyed  by  pressure ;  and 
it  is  here  that  the  caries,  which  proves  fatal,  begins.  But  it  is 
further  to  be  remarked,  that  the  sella  turcica  lies  immediately 
above  the  cleft  of  the  nostrils,  and  the  two  anterior  lobes  of  the 

plan  no.  4. 


Of  Tumours  of  the  Nostrils,  Gums,  end  Throat.         423 

brain  lie  in  hollows  by  the  sides  of  the  sella  turcica ;  you  have 
here  then  all  the  essential  relations  of  these  bony  cells  to  the 
poApus,  and  must  perceive,  that  as  soon  as  the  tumours  (a  a), 
fill  the  whole  cavities  (b  b),  distend  them,  and  in  the  end  press 
upon  them,  they  will  produce  caries  by  such  pressure,  as 
speedily  as  an  aneunsmal  tumour:  that  such  caries  will  be  long 
of  affecting  the  septum,  because  it  is  mass)-,  and  yet  can  give 
wa\  and  be  inclined  to  one  side  ;  but  will  affect  more  immedi- 
ate iy  the  thin  partition  betwixt  the  nostril  and  the  antrum,  and 
la\  them  into  one  cavity.  The  cribriform  plate  of  the  ethmoid 
bone,  which  lies  immediately  before  the  sella  turcica,  and  above 
the  nostrils,  will  be  next  affected  ;  and  indeed  one  of  the  ear- 
liest signs  of  polypus  is  a  degree  of  stupor  from  pressure  on  the 
brain  ;  and  one  of  the  most  frequent  and  fatal  conclusions  of 
the  disease  is  a  continued  coma,  for  several  days  preceding  death. 
But  more  frequently  the  upper  jaw-bone  is  destroyed  ;  the  tu- 
mour makes  its  way  into  the  antrum  ;  the  whole  upper  jaw-bone 
becomes  carious ;  the  teeth  drop  from  their  places  ;  and  a  fetid 
matter  distiis  from  their  sockets  ;  and  the  patient  dies,  wasted 
by  pain  and  ha;morrhagy. 

Such  is  the  condition  of  these  long  and  pendulous  polypi, 
which  should,  from  their  consequences,  have  been  pronounced 
peculiarly  malignant :  in  the  tumours  themselves  there  is  no 
token  of  malignity  ;  in  the  state  of  the  bones,  there  appears 
destruction  enough  to  account  for  the  fetor,  the  pains,  the  pro- 
fusion of  matter,  and  all  the  worst  symptoms  of  the  disease, 
during  life  ;  and  for  the  miserable  manner  of  the  patient's  death. 

Polvpus  has  sometimes,  independent  of  any  innate  malignity, 
and  rarely  from  its  peculiar  situation,  a  verv  peculiar  aspect, 
and  runs  its  course  more  rapidly.  I  am  confident,  I  have  ob- 
served that  when  polypus,  which  in  its  early  stage,  is  usually 
attended  with  no  worse  signs  than  sneezing  and  ruaning  of  the 
head,  is  attended  with  rheumatic  and  toothachv  pains  ;  when 
the  side  of  the  face  swells,  before  the  natural  growth  of  the  tu- 
mour should  produce  this  alarming  change,  and  the  cheek-bone 
particularly  rises,  and  is  covered  with  inflamed  and  puftv  in- 
teguments ;  when  the  incessant  and  acute  pain  is  limited  to  one 
side  of  the  face  ;  when  the  teeth  loosen,  drop  out  successively 
from  their  sockets,  and  are  followed  by  a  sanious  and  fetid 
charge,  we  mav  be  assured  of  the  polvpus  having  one  kind  of 
malignity,  viz.  that  it  is  confined  within  a  narrow  cavitv,  that 
it  is  seated  in  tht  antrum,  that  the  cheek  and  jaw-bones  will  be- 
come early  carious,  while  the  destructive  pressure  is  operating 
also  in  every  other  direction  ;  and  that  the  polj  pus  being  within 


424        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

the  antrum,  the  operation  of  noosing  is  not  practicable,  and  no 
ordinary  operation,  nor  common  degree  of  violence  is  likely  to 
be  successful  in  eradicating  the  disease.  Thus  far  is  early  pain 
a  sign  of  greater  malignity,  or,  in  other  terms,  of  that  de- 
structive pressure,  which  in  the  end  causes  caries,  haemorrhagy, 
and  death. 

One  thing  more  I  beg  leave  to  observe :  it  seems  to  me  that 
the  predisposition  to  disease  is  universal  in  the  Schneiderian 
membrane  ;  that  the  earliest  appearance  of  the  disease  is,  in 
general,  swelling,  especially  of  that  part  of  the  membrane, 
which  involves  the  spongy  bones  ;  that  almost  universally  the 
disease  is  produced  by  cold  ;  that  many  of  those  who  have  been 
under  my  care,  having  got  wet  in  riding,  running,  or  other 
exercise,  have  had  a  sudden  and  sensible  cold,  attended  with 
violent  paroxysms  of  sneezing,  which  has  never  for  a  moment 
ceased,  till  the  polypus  was  perfectly  formed,  the  breathing  ob- 
structed ;  the  particular  character  of  the  tumour,  viz.  that  of 
moving  backwards  and  forwards  with  the  breath  becomes  per- 
ceptible, and  the  polypus,  in  short,  tangible  with  the  finger. 
Where  the  polypi  are  incipient  only,  they  are  flat  and  bread, 
have  no  pedicle,  do  not  hang  pendulous,  but  seem  merely  a 
general  swelling  of  the  membrane ;  in  some  cases  while  the 
complete  polypi  in  one  nostril  are  long,  slender,  and  pendulous, 
the  incipient  polypus  in  the  other  is  flat,  membranous,  resemb- 
ling one  of  the  nymphae  in  form,  without  a  pedicle,  and  to  all  ap- 
pearance a  general  swelling  of  the  membrane  :  but  I  hold  it  un- 
questionable, that  such  an  enlargement  would  in  no  longtime  be- 
come a  conical  polypus,  for  it  seems  to  me  that  the  neck  or  pedicle 
is  formed  by  time,  and  the  pendulous  posture  of  the  tumour :  but 
a  conclusion  far  more  important,  not  certain  indeed  but  probable, 
and  not  unworthy  of  consideration,  follows,  viz.  that  since  the 
disease  often  is  formed  instantly,  and  sensibly,  after  a  violent 
and  sudden  rheum  or  cold,  and  as  it  consists  at  first  in  a  mere 
relaxation  of  the  membrane,  there  is  a  stage  in  which  it  is  per- 
haps curable  by  astringent  solution,  and  the  use  of  caustic. 

From  the  conceptions  which  now  open  upon  you  of  the  na- 
ture of  this  disease,  you  must  naturally  suppose,  that  in  place 
of  arranging  polypi  according  to  the  imaginary  characters  of 
soft,  and  hard,  mild,  and  malignant,  I  should  rather  define  the 
several  stages  and  periods  of  its  growth,  and  describe  the  opera- 
tions corresponding  with  each  stage.  It  is  not  by  books  nor 
conversation,  that  you  will  ever  be  able  to  decide  which  mode 
of  extirpating  a  polypus  is  to  be  preferred  :  you  will  learn  only, 
that  some  have  used  ligature,  some  caustic,  some  forceps,  some 
the  cautery,  some  heated  irons,  some  long  needles,  with  which 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat.        425 

they  have  bored  and  transfixed  the  polypus !  That  old  surgeons 
have  been  in  the  practice  of  cleaving  the  palate  most  unrelent- 
ingly, to  get  at  those  polypi  which  hang  in  the  throat ;  while 
others  have  most  audaciously  proposed,  to  cut  open  the  nostrils 
and   cheek-bones !  Each  praises  his  own  method  as  invariably 
successful ;  and  the  imagination   of  the  young   surgeon  being 
left,  distracted  among  such  a  chaos  of  inventions,  though  he  is 
at  a  loss  to  choose,  never  doubt*,  that  with  such  a  variety  of 
means  before  him,  and  the  privilege  of  trying  one  after  another, 
he  cannot   entirely  fail.      Many  an    operation,  good    and   bad, 
successful  and    unsuccessful,  have   I  witnessed  ;    and  certain 
practical  conclusions,   which  I   neither   sought  nor   imagined, 
have  come  to  be  established  in  my  mind  ;  but  especially  these  : 
That  the  surgeon  who  attempts  to  noose  a  polypus  of  the  nos- 
tril, invariably   miscarries  ;    yet    this    is   the  kind  of  polypus, 
which  being  easily  seen  and  felt,  is  supposed  to  be  most  easily 
noosed.     That  the  big  and  bulbous  polypus,  which  descends  by 
the   back  of  the  nostrils  towards  the  throat,   and  depresses  the 
soft  palate,  though  usually  shunned  as  too  bulky  to  be  grappled 
with,  is    truly  the  most   favourable    for  this  operation  ;  this  is 
indeed  the  only  period  of  its  growth,  in  which  the  polypus  can 
be  effectually  noosed.     That  the  polypus  which   has  its  root 
within  the  antrum  maxillare,  is  characterised  by  early  and  per- 
manent pain,  the  caries  of  the  jaw-bone,  and  the  dropping  out 
of  the   teeth,  and  that  it  is   not  to  be  reached  with  the   silver 
tubes   of  Levret,  nor  to  be  noosed,  nor  extracted  by  ordinary 
methods,  is  too  obvious  to  require  illustration  :  it  is  equally  ob- 
vious, that  the  polypus  which  has  already  burst  up  the  cells,  and 
produced  a  general  caries  among  the  spongy  bones,  is  past  all 
surgery:  That  the  extraction  of  the  polypus  in  such  disastrous 
circumstances,  only  hurries  on  the  catastrophe,  as  I  shall  prove 
by  sad  memorials.     After  being  long  perplexed,  as  every  one 
must  be  who  takes  his  first  ideas  from  books,  concerning  the 
preferable  modes  of  practice,  I  learnt  from  experience,  what  I 
regard  as  a  discovery  more  precious  and  useful  than  that  of  the 
most   curious  instruments,   viz.  that  each  stage  of  the  disease 
requires  an  appropriate  operation  ;  so  that  each  method,  in  its 
turn,  becomes  valuable  ;  and  that  with  judicious  distinctions, 
and  moderate  skill,  every  polypus   has  its  appropriate  mode  of 
.  except  in  its  last  and  fatal  stage. 
I  am  now  to  define  the  several  stages  in  the  growth  of  poly- 
which  require   appropriate   operations ;  but  do  not  flatter 
\  ourselves,  that,  because  all  seems  clear  and  simple  in  descrip- 
tion, every  thing  will  be  so  in  practice  :   I  am,  indeed,  an  en- 
thusiast,  but  not  in  this  degree  ;  for  though  I  hope  and  mean 
to  make  the  subject  very  simple,  vet  vou  are  in  vour  turn  to 

3H 


426        Of  Tumours  of  the  Nostrils,  Gums,  and  Throat. 

have  your  disappointments  and  uncertainties.  You  are  neither 
to  judge  by  your  eye,  feel  with  \  our  fingers,  nor  act  with  your 
instruments  so  pei  fectly,  nor  so  dexterously  as  you  might  expect. 

1.  In  its  early  stage  polypus  has  invariably  that  character 
which  is  usually  denominated  mild :  it  is  small,  moveable, 
pale,  colourless,  and  has  not  as  yet  begun  to  affect  the  adjacent 
parts  by  the  pressure;  there  is  a  watering  of  the  eyes,  sneezing, 
altered  voice,  and  interrupted  breathing,  but  as  yet  no  pain,  nor 
any  fetid  ichor  distilling  from  the  nose  :  from  the  smaliness  and 
pendulous  direction  of  such  polypus,  to  noose  it  is  difficult;  and 
from  the  numbers  of  smaller  polypi  which  usually  lurk  one 
behind  another,  the  perfect  extirpation  of  all  of  them  by  apply- 
ing the  noose  is  nearly  impossible.  The  happiest  and  most  suc- 
cessful process  is  to  extract  the  bod)-  or  bulky  part  of  such  polypi 
with  forceps,  and  to  destroy  their  roots  with  caustic. 

2.  In  its  next  stage,  the  polypus  grows  to  a  great  bulk,  not 
only  fills  the  nostril,  but  is  visible  in  the  throat,  the  voice  is  en- 
tirely changed,  for  not  a  breath  of  air  reaches  the  bony  cells, 
nor  passes  through  the  nostrils  :  the  hearing  is  greatly  affected  ; 
if  you  introduce  your  fingers  deep  into  the  throat,  you  feel  a 
tumour  so  bulky,  as  at  once  to  depress  the  soft  palate,  and 
compress  entirely  the  mouth  of  one  or  both  Eustachian  tubes  : 
the  face  is  swelled  and  unsightly,  the  nose  inclined  to  one  side, 
blood  begins  occasionally  to  flow,  and  the  matter  distilling  from 
the  nostrils  and  throat  begins  to  be  fetid  ;  the  pressure  is  now 
universal,  and  begins  to  affect  the  bones,  and  the  disease  bor- 
ders on  that  stage  which  is,  I  fear,  incurable. 

This  bulky  and  seemingly  dangerous  polypus,  terrifies  the 
young  surgeon :  he  reads  in  elementary  books  only  of  trivial 
tumours  appearing  in  the  nostril,  and  is  alarmed  when  he  sees 
a  polypus  of  this  enormous  size  :  he  has  read  in  books  of  cases, 
of  polypi  thus  oppressing  the  patient  and  descending  into  the 
throat,  but  he  recollects  that  the  surgeons,  in  these  desperate 
circumstances,  committed  every  kind  of  devastation,  they  of- 
ten cleft  the  palate  to  reach  the  tumour,  and  were  willing  even 
to  perforate  the  trar.hen  :  yet  this  case,  or  this  stage  rather  of 
the.  disease,  is  not  desperate  ;  it  is  indeed  on  the  verge  of  that 
period  in  which  the  polvpus  is  incurable,  but  from  its  very  bulk 
it  is  easily  and  effectually  noosed.  1  find  not  the  slightest  diffi- 
culty in  this  case;  passing  a  silver  wire  through  the  nostril, 
bringing  it  out  through  ihe  mouth,  and  with  the  points  of  the  fin- 
gers (thrust  deep  into  the-  throat)  raising  it  over  the  bulbous  and 
most  dependent  part  of  the  tumour,  I  draw  it  back  into  the  nos- 
tril, and,  as  it  appears  to  me,  quite  to  the  neck  of  the  tumour, 
for  I  have  often  succeeded  thus,  and  never  found  reason  to  seek 
the  roots  of  the  polvpus,  or  apply  caustic. 


Of  Tumours  of  the  Nostrils,  Gums,  and  Throat  J       427 

3.  In  its  third  and  last  stage,  when  the  passages  of  the  nos- 
trils and  throat  have  been  long  obstructed,  and  the  face  much 
deformed;  when  the  patient  has  long  endured  the  rending  head- 
achs,  and  pains  proceeding  from  the  distention  ;  when  the  sur- 
geon can  distinguish,  by  pressing  with  his  fingers,  that  the  cheek- 
bones are  softened,  and  the  nasal  bones  become  moveable,  and 
fetor  and  hsemorrhagies  intimate  the  caries  within  ;  when  the 
integuments  of  the  faee  are  puffy,  the  skin  reddened,  or  livid, 
over  the  root  of  the  nose,  and  the  teeth  loosened  ;  when  the  stu- 
por from  pressure  .on  the  brain,  and  the  chilliness  from  want  of 
nourishment  and  loss  ofbTotftl  are  great  and  continual,  the  dis- 
ease is  declining  into  its  last  stage,  which  we  can  hardly  palliate, 
and  cannot  cure.  This  is  the  stage  of  the  disease  reputed  can- 
cerous, and  operations  undertaken  in  these  circumstances,  and 
perlormed,  as  I  have  seen  them  with  rudeness,  inflame  the  brain, 
so  that  the  patient  presently  sinks  into  absolute  stupor,  and  dies. 

For  every  practical  purpose,  the  dtfin'uion  ot  these  three 
stages  is,  as  I  judge,  altogether  sufficient. 


DISCOURSE  XXIII. 


OF  THE  VARIOUS  OPERATIONS  PRACTICA- 
BLE IN  THE  SEVERAL  STAGES  OF  POLY- 
PI. 


Of  the  first  Stage ;  or,  of  small  and  incipient  Polypi. 

SECTION    I. 

JL  HE  first  stage  of  polypus  I  no  longer  characterize  by  symp- 
toms, the  enumeration  of  these,  I  hope,  I  am  entitled  to  omit 
in  future.  I  am  now  to  speak  of  the  extirpation,  ol  the  means 
of  eradicating,  not  apparentlv,  but  effectually,  that  smaller  po- 
lypus, which  hangs  forwards  in  the  nose,  and  only  obstructs  trt£ 
nostrils.  Of  the  operation  of  ligatures  I  have  spoken  with 
little  restraint,  I  know  too  well  what  is  usually  done,  what  can 
be  done  by  Levret's  tubes,  to  mention  that  method  with  respect. 


428  Of  small  and  incipient  Polypi. 

On  this  subject  I  will  use  but  one  plain  blunt  expression,  and 
take  notice  that  I  say  no  worse  of  the  attempts  of  others  "than  I 
do  of  my  own,  (for  I  have  many  times  attempted  this  method.) 
That  the  disappointment  of  those  who  confidently  expect  and 
promise  to  noose  such  small  tumours,  is  so  lrequent  and  so  lu- 
dicrous, that  I  should  be  loath  to  quote  examples  :  many  are 
the  times  I  have  seen  the  surgeon  thrust  his  tubes  and  wires 
into  the  nostrils,  and  withdraw  them  again,  leaving  the  nose 
streaming  with  blood  :  the  attempt  is,  on  such  occasions,  re- 
peated without  delicacy  or  mercy,  and  if  he  but  so  fix  his  tube 
that  it  can  hang  without  dropping  away  by  its  own  weight,  he 
willingly  leaves  it  there,  and  trusts  his  reputation  to  this  first 
appearance  of  success.  But  it  drops  away  on  the  second  day, 
the  breathing,  the  voice,  the  hearing,  are  still  affected  as  they 
were  before  ;  even  were  there  but  one  polypus,  (and  you  know 
by  these  drawings,  and  I  assure  you  from  experience,  that  there 
are  usually  many)  a  second  would  immediately  descend,  and 
occupy  the  place  of  the  first.  But  where  a  ligature  is  thus 
slightly  applied,  the  point  only,  the  mere  bulb  alone,  of  the 
polypus,  is  cutoff;  the  nostril  is  so  far  closed,  that  the  breath- 
ing is  lor  a  moment  more  free,  but  the  long  neck  and  root,  from 
which  the  disease  germinates  again,  remain  untouched,  and  the 
individual  tumour,  which  is  the  subject  of  the  operation, 
sprouts  again  with  renovated  vigour  in  a  few  days.  This  then 
is  a  harmless,  but  it  is  as  certainly  an  useless  operation  ;  I  knew 
not  how  very  trifling  it  was,  till  I  had  often  failed  :  be  assured 
that,  however  much  you  may  be  captivated  with  these  ingeni- 
ous tubes  of  Levret,  for  applying  ligatures,  and  though  you 
may  be  still  more  captivated  with  your  own  inventions,  (for  eve- 
ry one  invents  instruments  for  extracting  polypi)  be  assured 
that  a  grievous  disappointment  awaits  you,  which  I  now  warn 
you  of.  As  Richter  observes,  there  are  but  two  methods  of 
extirpating  polypus,  viz.  by  ligature,  or  by  forceps,  and  ever 
since  the  time  of  Levret,  who,  from  a  horror  at  hsemorrhagv, 
and  the  fear  of  tearing  away  the  spongy  bones,  invented  instru- 
ments for  passing  the  ligature,  surgeons  have  uniformly  prefer- 
red the  ligature  to  forceps. 

I  will  not  allow  myself  to  protract  my  discourse  by  any  but 
occasional  hints  of  the  irregular  and  inefficient  practices  of  the 
earl)7  surgeons,  nor  defer  what  must  be  interesting  to  you,  the 
simple  account  of  what  experience  has  taught  me  :  I  was  early 
aware  of  the  little  advantage  to  be  derived  from  the  ligature  in 
smaller  polypi,  and  learnt  to  use  the  forceps,  the  knife,  and  the 
caustic  with  particular  freedom.  I  fear  I  tell  you  no  more  than 
the  truth,  when  I  say  that,  in  my  mind,  every  operation  for 
polypus,  must  be  one  way  or  other,  rude  and  cruel,  to  be  at  all 


Of  small  and  incipient  Polypi.  429 

successful ;  and  that  these  nice  and  curious  methods  must  be 
unavailing. 

The  forceps,  knife,  and  caustic,  are  the  means  I  have  found 
most  suitable  to  the  smaller  polypi  ;  and,  according  to  the  con- 
ceptions I  form  of  each  particular  tumour,  according  to  the  pe- 
riod of  its  growth,  the  symptoms  and  effects  of  its  pressure, 
and  by  searching  with  the  probe,  or  fingers,  I  use  those  instru- 
ments variously,  and  pursue  them  according  to  the  progress  and 
effect  of  the  operations.  I  begin  with  the  forceps,  and  con- 
clude with  the  caustic,  and  1  find  the  extirpation  ol  a  polypus, 
and  the  killing  of  its  roots,  not  an  operation  to  be  performed 
with  such  a  show  of  dexterity  as  to  captivate  the  pupils  who 
assist  or  are  present ;  1  find  it  to  be  a  work  at  once  slow  and 
difficult,  and  often,  I  fear,  it  is  imperfectly  accomplished. 

It  is  assuredly  neither  the  root,  nor  even  the  body  of  a  po- 
lypus, that  you  are  able  to  seize  with  the  forceps  ;  but  the  bul- 
bous point  only  ;  for  you  will  observe  in  all  these  drawings,  that 
the  neck  of  the  polypus,  and  all  that  hangs  in  the  passage,  is 
slender  and  delicate,  that  it  forms  a  bulb  only  where  it  hangs 
below  the  narrowed  slit  of  the  internal  nostril,  or  behind  the 
palate  ;  that  it  is  of  this  bulb  only,  that  I  can  catch  a  slippery 
and  insecure  hold,  so  that  you  may  sometimes,  in  consequence 
of  the  slenderness  of  the  neck,  and  by  a  sort  of  accident,  twitch 
it  off  lrom  its  narrowest  part,  and  close  to  the  spongy  bone. 
The  pedicle  sometimes  gives  way  spontaneously,  the  tumour, 
dropping  into  the  fauces  :  and  it  will  often,  by  a  happy  chance, 
break  off  from  the  root  in  extracting.*  In  such  operation  no 
man  need  affect  unusual  address  :  if  the  bulb  retires  be  lore  the 
instruments  when  pushed  into  the  nostril,  he  has  then  a  bitter 
chance  of  catching  the  neck :  the  bleeding  so  much  dreaded, 
and  made  an  argument,  almost  the  sole  one  by  Levret,  for  a- 
dopting  his  method  by  ligature,  is  indeed  extremely  slight: 
from  much  experience  I  can  assure  you,  that  such  haemorrhagy 
will  never  weaken  the  patient,  nor  require  a  plug,  which  yet 
should  always  be  in  readiness  ;  but  it  is  not  so  in  extirpating 
the  roots  of  the  tumour  with  the  knife,  then  the  haemorrhage 
is  great.  Both  nostrils  are  usually  diseased,  and,  on  the  first 
day,  I  extract  whatever  polypi  present  in  either  nostril ;  but, 
far  from  imagining  that  I  have  done  all  my  duty  to  the  patient, 
I  proceed  at  the  next  visit,  and  indeed  at  every  following  visit,  to 


*  The  forceps,  as  they  arc  now  formed,  feldom  catch  a  fecure  hold.  T  hofe 
commonly  ufed,  and  belt  known  by  the  name  of  lJolypus  Forceps,  are  entirely 
nfelels;  are  bigger  than  the  linger  and  give  no  hold.  Their  blades  are  too  broad. 
Thole  which  I  prefer  and  ule  are  (null,  long,  delicate,  and  their  fhengthis  put 
upon  the  thicknefs,  not  upon  the  breadth  ol  the  blade  ;  they  enter  ealily,  and  catch 
well. 


430 


Of  small  and  incipient  Polypi. 


search  for  polypi,  or  their  remains.  Some  polypi,  I  find,  come 
out  entire,  as  I  judge  by  their  form  ;  others,  manifestly  short 
of  their  full  dimensions,  and  mangled.*  The  anterior  nostril 
being  cleared,  I  see  down  into  the  nasal  slit,  and  feel  deeper 
with  my  finger:  often,  upon  looking  into  the  nostril,  I  see, 
even  at  a  late  stage  of  mv  operations,  the  remains  of  a  polypus, 
or  feel  it  with  the  extremity  of  my  finger,  and  still  more  fre- 
quently I  am  sensible  of  eradicating,  by  various  m<  thods,  po- 
lypi which  are  too  deep  to  be  visible  ;  for  behind  the  narrow 
slit  which  the  finger  cannot  pass,  the  nostril  is  enlarged,  and  in 
that  wider  part,  usually  the  vomer  is  pressed  to  one  side,  there 
is  left  a  hollow  in  which  the  polypi  hang.  It  is  only  by  con- 
tinual examination,  and  the  most  earnest  attention,  and  a  care- 
ful calculation  of  points  and  distances,  that  such  remains  of 
polypi  are  discovered :  first,  by  a  rattling  noise,  when  the  breath 
is  driven  through  the  nostril,  which,  though  tolerably  free,  is 
so  only  at  times,  and  in  particular  postures  :  secondly,  by  feel- 
ing with  the  probe,  or  with  a  bigger  instrument,  when  we  per- 
ceive that  the  back  passage  is  not  clear,  the  point  of  the  instru- 
ment (I  often  use  the  Sound)  encountering  a  resistance  when 


•  too.  7.  a  polypus  of  full  fize,  root  and  all.     No.  8,9,  10, 11,  polypi  fhor:  ei 
their  natural  dimensions,  or  extracted  in  fragments. 


Of  small  and  incipient  Polypi.  431 

it  should  descend  to  the  back  of  the  nostril,  so  as  to  touch  the 
velum  ;  the  resistance  we  are  sensible  is  not  solid,  such  as 
would  proceed  from  the  probe  encountering  one  of  the  spongv 
bones,  but  soft  and  yielding,  such  as  we  are  sensible  we  could 
overcome  by  dashing  the  instrument  down  into  the  throat : 
thirdly,  when  the  patient,  in  consequence  of  our  first  operations, 
inhales  his  breath  freely,  but' cannot  breathe  out  with  tqual  fret- 
dom,  we  are  sure  that  a  pol\  pus,  or  the  remains  of  one,  is  still 
hanging  in  the  back  part  of  the  nostrils,  ntan  r  the  palate  ;  act- 
ing like  a  valve,  it  recedes  when  the  patient  draws  in  his  breath, 
but,  when  he  breathes  out,  it  falls  flat  upon  the  back  of  the  nos- 
tril and  prevents  the  exit  of  the  air.  Now,  although  I  am 
pleased  when  I  see  the  stupor  lessen,  the  breathing  more  free, 
and  the  hearing  restored,  I  am  conscious  that  all  is  not  safe,  and 
that  there  must  be  added  other  essential  signs  of  the  passage 
being  free.  It  is  in  this  stage  that  the  patient  is  usually  dis- 
missed, and  most  inhumanly,  with  some  trivial  directions  of 
introducing  bougies,  or  drawing  astringent  solutions  up  the 
nostril,  to  return  in  a  (c\v  months  with  an  incurable  and  carious 
disease  of  all  the  bones.  When  I  find  that,  though  the  pa- 
tient breathes  easily,  the  head  reclining  backwards,  he  cannot 
breathe  in  the  natural  and  perpendicular  posture  ;  when  I  find 
that  though  he  inhales  the  breath  easily,  he  finds  it  suddenly 
and  vehemently  stopped,  however  strongly  and  perseveringly 
hz  presses  it ;  when  I  find  (suspecting  from  those  signs  some- 
thing wrong)  that  though  the  anterior  nosiril  is  free,  some  co- 
loured body  appears  within  the  nasal  slit,  is  felt  with  the  finger, 
though  indistinctly,  and  is  directly  encountered  by  the  Sound, 
or  big  probe,  passed  from  the  nostril  towards  the  throat;  when 
I  find  that  his  breathing  (even  alter  having  become  free)  after 
he  is  able  to  dash  out  b\  vehement  efforts,  the  prodigious  quan- 
tity of  thickened  mucus,  which  the  inflamed  state  ot  the  nostril 
generate  s,  is  yet  accompanied  with  a  rattling  and  snorting  noise  ; 
when  that  peculiar  noise  continues  alter  the  nostril  is  cleanse  d  by 
snorting,  and  by  wiping  it  within  with  the  probe  covered  with 
lint,  I  am  sure  there  are  some  dangerous  remains  of  the  disease. 
Often  I  see  this,  after  I  have  begun  to  apply  the  caustic,  and 
discover  the  remains  of  the  polypus,  rounded  bv  ulceration,  of 
a  brilliant  colour  and  bud-like  ;  but  never,  alter  this  stage,  do  I 
expect  good  from  the  forceps  :  I  proceed  to  rougher  and  more 
decisive  methods. 

When  I  find  the  whole  of  the  posterior  nostril  closed  by  a 
spongv  polypus,  which  I  either  have  not  reached,  or  have  ex- 
tirpated imperfectlv,  I  have  recourse  to  the  knife:  whi  n  I  first 
ordered  knives  to  be  forged  for  me  of  the  form  represented  in 
No.  6.  I  little  imagined  I  had  the  least  authority  for  proceed- 


432  Of  small  and  incipient  Polypi. 

ing  in  this  enterprising  way  ;  yet  I  find  that,  far  from  having 
neglected  those  passages  of  ancient  authors,  where  the  use  of 
the  knife,  and  the  spathula,  which  was  a  sort  of  knile,  was  men- 
tioned by  Celsus,  and  by  the  Arabians,  I  had  made  accurate 
notes  of  their  methods,  which  I  had  yet  so  entirely  forgotten, 
as  to  proceed  in  cutting  out  polypi,  with  all  the  timidity  ot  one 
who  was  attempting  a  thing,  at  once  unprecedented  and  danger- 
ous.    I  recollected  no  precedents,  and  reasoned  only  on  the  ne- 
cessity, on  the  simplicity  of  the  operation,  and  by  analogy  in- 
ferred, that  if  we  might  extirpate  a  tumour  of  the  cheek,  or  lip, 
of  the  palate,  or  tonsil,  with  the  knife,  much  more  should  we 
adventure  to  extirpate  that  of  the  nostril,  since,  by  drawing  up 
plugs  into  the  nostril  from  behind,  we  could  entirely   suppress 
whatever  ha^morrhagy  any  operation  produced  ;  we   could  ap- 
prehend nothing  from  the  wounding  of  the  spongy  bones,  and 
the  operation  of  incision,  in  place  of  the  rude  method  of  tear- 
ing and  mangling  with  forceps,  seemed  more  delicate  in  rela- 
tion to  the  membrane,  and  more  effectual  in  respect  to  the  tu- 
mour.      I  have  never  since  that  period  (now  many  years  past) 
spared  the  knife  in  operations  of  this  nature:  often  I  have' used 
it  in  the  first  operations,  and  in  place  of  pulling  away  the  more 
bulky  polypi  with  the  iorceps,  have  slipped  in  the  knife  into  the 
nostril,  and  carrying  it  flat  and  vertical,  till  I  reached,  accord- 
ing to  my  apprehension,  the  root  of  the  tumour,  have    then 
turned  the  edge  towards  it,  and  with  some   mangling,  and  not 
without  both  difficulty  and  fear,  have  cut  it  off.     But  when  the 
nostril  is  already  in  some  degree  clear,  when  the  anterior  nos- 
tril is  free  in  so  far  as  to  admit  the  knives  easily,  but  the  pos- 
terior nostril  still  encumbered  with  tumours,  or  the  remains  of 
tumours,  I   find  it  particularly  advantageous,  to  pass  the  knife 
deep  through  the  nostril,  till   it  lies  in  the  posterior  opening  of 
the  nostril  over  the  palate  ;  then  turning  the  knife,  and  striking 
a  stroke  alternately  to  right  and  left,  or  cutting  with  premedi- 
tation in  that  direction,  in  which  from  the  probe,  or  the   cir- 
cumstances of  the  breathing,   I  suspect  the  tumour  to  hang,  I 
free  the  nostril  of  this  last  obstruction.     I  do  not  know  a  greater 
happiness  for  the  patient,  or  a  greater  victory  on  the  part  of  the 
surgeon,  than  that  of  clearing  the  nostrils  of  this  very  danger- 
ous disease :  in  whichsoever  relation  I  stood,  of  patient  or  of 
surgeon,  I  would  set  no  limits  to  the  sacrifices  I  would  make 
for  such  a  purpose  :   I  have  ever  remarked,  that  the  period  of 
suffering  on  the  part  of  the  patient,  or  of  necessary  cruelty  on 
the  part  of  the  surgeon,  though  seemingly  long,  is  really  tran- 
sient, and,  when  the  end  is  accomplished,  on  the  return  of  health 
and  pleasure,  when   freedom  of  breathing,  and  of  hearing  is 
restored,  is  entirely  forgotten.      Therefore,   I  intreat  you  in 


Of  small  and  incipient  Polypi.  433 

all  such  cases  to  persevere  :  there  is  but  one  immediate  dan- 
ger, viz.  that  or  haemorrhagy  ,  and  I  leave  you  to  judge,  whe- 
ther any  incision  these  knives  can  make,  although  it  were  di- 
rectly into  the  membrane  and  among  the  spongy  bones,  much 
less  such  as  is  made  into  the  slender  neck  or  body  of  a  tumour 
so  small  as  to  be  contained  within  the  nostril,  could  be  danger- 
ous !  Confident  that  it  could  not,  I  have  ulways  used  the  knife 
freely,  and,  though  I  have  had  the  plugs  for  suppressing  hse- 
morrhagy  ready,  and  have  usually  indeed  had  the  ligature  rea- 
dy passed  from  the  nostril  to  the  throat,  prepared  to  draw  up 
the  plug,  1  have  not  more  than  twice  or  three  times  at  the  ut- 
most had  occasion  to  draw  it,  and  then  only  to  save  the  strength, 
and  lessen  the  alarm  of  the  patient,  not  to  save  his  life. 

Let  me  now  represent  to  you,  after  these  general  descripti- 
ons, the  particular  acts  of  these  successive  operations. 

1st,  For  the  extraction,  you  must  be  conscious,  that  with  the 
best  imagined  forceps,  you  can  grasp  only  the  bulb  or  most 
pendulous  point  of  the  polypus  ;  that  if  you  are  successful  in 
twitching  out  tne  polypus  by  its  root,  it  must  be  by  your  good 
fortune  in  having  to  deal  with  a  pol)  pus  whose  root  is  natural- 
ly delicate ;  that  your  forceps  are  to  be  used  with  any  degree 
of  success,  they  must  be  so  formed  as  to  operate  with  their 
blades  vertical,  viz.  one  towards  the  forehead,  the  other  towards 
the  chin  of  the  patient  ;  or,  in  other  words,  according  to  the 
length  of  the  nasal  slit. 

2d,  Whether  to  amputate  entire  polypi,  or  to  eradicate  those 
which  have  been  partly  extracted,  you  will  do  better  to  use  a 
knife  sharp  on  its  convex  edge.  Those  fashioned  like  the  one  in 
plan  No.  6,  which  ihave  hitherto  used,  will  be  found  occasionally 
very  convenient,  especially  in  cutting  at  the  roots  of  polypi  ly- 
ing far  back  in  the  nostril,  or  in  the  arches  of  the  palate,  and 
where  you  are  to  make  your  cut  by  hooking  the  crooked  knife 
beyond  the  root  of  the  tumour,  and  drawing  it  towards  }'ou. 
But  I  am  conscious  that  1  could  manage  the  form,  No.  5,  with 
perfect  safety,  and  it  is  manifest  that  I  could  cut  more  decided- 
ly with  it ;  for  the  polypi  hang  down  from  the  upper  spongy 
bones,  in  the  form  1  have  represented  in  all  the  drawings,  and 
especially  in  the  drawings,  No.  1,  and  3,  but  which  I  have  more 
correctly  represented  in  the  plan  No.  6,  which  I  drew  in  the 
time  of  operating,  and  lor  the  correctness  of  which  I  can  be  re- 
sponsible. After  long  reflection  and  many  partial  operations 
on  this  patient,  I  sketched  this  plan  the  moment  after  my  fin- 
ger and  instruments  were  out  of  the  nostrils.  As  soon  as  the 
gentleman,  being  freed  from  puin,  could  sit  composedly  and 
without  suffering,  he  seated  himself  before  me,  while  I  made 
the  plan,  with  everv  recollection  and  feeling  fresh  and  livelv. 

3  I 


434 


Of  small  and  incipient  Polypi. 


In  this  plan  are  represented  the  features  in  profile  ;  the  cavity 
or  hollow  formed  by  the  bending  aside  of  the  vomer  or  parti- 
tion of  the  nose;  the  roots  of  one  pol\  pus  already  extirpated, 
the  remaining  root  being  still  sufficiently  long  to  appear  move- 
able upon  looking  into  the  nostril,  and  exposed,  ol  course,  to 
the  stroke  of  the  knife,  and  requiring  it ;  another  pol\  pus  entire, 
and  deeper  seated,  obstructed  the  back  of  the  nostril,  allowing 
the   patient  to  draw  his  breath,  but  falling  down  valve-like,  so 

plan  no.  5. 


PLAN  NO.  6. 


as  to  prevent  the  breath  being  driven  out :  (a)  a  semicircular 
dotted  line  marks  the  place  where  the  < ;  rtilaginous  wing  of  the 
nose  terminates,  and  the  opening  of  the  nostril  is  narrowed  by 


Of  small  and  incipient  Polypi.  435 

the  arch  of  the  nasal  bone  :  ( b  b)  the  hollow  produced  by  the 
receding  of  the  vomer  towards  the  Lit,  b  ing  pressed  b\  the 
bulk  ot  the  polypus:  ft  J  marks  the  upp<r  spongy  bone,  where 
the  poly  pi  had  their  roots  :  (d)  the  remains  of  a  large  polypus, 
which  had  originally  filled  the  whole  opening  of  the  nostril,  and 
ol  which  only  the  root  (dj  is  left,  hut  was  left  of  such  a  length 
as  to  require  a  stroke  ol  the  knile  :  (e)  the  direction  of  the 
lower  spongy  bone  represented  in  a  dotted  line.  This  lower 
spongv  bone,  hanging  on  the  edge  ol  the  antrum  under  the 
cheek-bones,  and  the  antrum  being  cut  away,  it  can  be  repre- 
sented onlv  bv  this  imaginary  line,  (fj  marks  a  longer  and 
more  entire  poh  pus,  which  so  obstructed  the  back  opening  ol 
the  nostril,  (viz.  that  towards  the  throat,)  that  neither  the  big- 
headed  probe,  nor  even  the  common  probe  or  director  could 
pa-^s  freely  :  fg)  demonstrates  the  direction  of  the  knife,  when 
passed  down  the  nostril,  towards  the  throat,  so  as  to  cut  the 
polypus,  in  withdrawing  it,  by  very  slightly  turning  its  edge. 
But  it  is  obvious,  that  had  I  used  knives  cutting  on  the  back, 
though  I  could  not  have  been  sure  to  conduct  them  so  harm- 
lessly through  the  nostril,  1  should  have  been  sure  of  using 
them  more  effectually  ;  for  a  knife  so  formed,  scythe-like,  and 
cutting  on  its  convex  edge,  could  not  have  failed  to  cut  off,  and 
that  probably  very  near  its  root,  whatever  polypus  hung  down 
from  the  upper  spongy  bone. 

3d.  For  the  suppressing  of  the  haemorrhagy,  it  is  necessary 
that  you  be  made  acquainted  with  the  introduction  of  the  noose, 
which  is  a  method  at  once  simple  and  effectual,  of  drawing  up 
a  plug  from  behind  the  palate  to  the  posterior  opening  of  the 
nostril,  so  as  to  have  it  in  your  power  to  close  at  once  both 
openings,  to  restrain  the  blood.  You  are  to  take,  not  a  piece  of 
catgut,  lor  that  is  liable  to  twist  very  provokinglv,  and  to  be  so 
softened  with  the  moisture  of  the  tauces  as  to  lose  its  shape  ; 
but  a  piece  of  delicate  silver  wire,  or  occasionally,  I  have  used 
a  harpsichord  wire,  and  doubling  it,  you  make  the  patient  gape, 
introduce  the  loop  of  the  wire  through  the  nostril,  and  watch  its 
appearanee  in  the  throat;  ihe  splendour  of  the  silver  wire  shows 
it  at  once  ;  if  vou  find  the  patient  not  at  all  excited  to  cough, 
you  may  be  assured  the  wire  has  not  yet  reached  the  fauces  ;  if 
he  is  in  clanger  of  suffocating,  you  may  be  assured  that  the 
loop  of  the  wire  actually  touches  the  epiglottis  ;  then  you  will 
retract  it  a  little,  and  the  irritation  will  cease.  The  way  to  suc- 
ceed is  to  carry  all  quietly  and  softly,  to  insinuate  the  wire 
along  the  nostril  very  gently,  to  watch  for  it  in  the  throat  care- 
fully, to  mark  its  ap  earance  instantly,  when  it  begins  to  pass 
behind  the  velum,  to  push  it  no  farther,  for  then  it  touches  the 
irritable  parts,  to  be  ready  with  the  crooked  probe,  or  the  dress- 


436  Of  small  and  incipient  Polypi. 

ing  forceps,  or  a  blunt  hook,  to  catch  it  the  instant  it  appears, 
and  draw  it  out  by  the  mouth.  Then,  in  the  loop  of  the  wire, 
you  fix,  with  a  piece  of  thread,  a  small  pad  of  charpie,  and 
make  ready  to  draw  it  back  through  the  mouth,  and  up  behind 
the  soft  palate,  into  the  back  of  the  nostrils.  You  prepare  for 
this  act  by  twining  the  wire  round  the  fingers  of  your  left  hand, 
near  the  nostril,  and  bv  holding  the  plug  upon  the  point  of  the 
fingers  of  your  right  hand  ;  you  then  draw  back  the  wire  through 
the  nostrils,  and  push  the  plug  into  the  mouth  by  correspond- 
ing motions  of  your  two  hands,  and  when  you  have  got  the  plug 
to  the  back  of  the  palate,  and  just  sticking  in  the  lauces,  you 
must  not  leave  it  a  moment  there,  but  by  a  sudden jtrk  with  the 
left  hand,  pushing  boldly  at  the  same  moment  with  the  fingers 
of  the  right,  you  bolt  it  up  into  the  posterior  opening  of  the 
nostrils,  above  the  back  of  the  palate,  and  fix  it  at  once  in  the 
cleft  at  the  back  of  the  nostrils.  This  being  finished  by  plug- 
ging, at  the  same  time,  the  opening  of  the  corresponding  nos- 
tril, there  is  no  longer  a  possibility  of  the  blood  escaping.  I 
have  several  times  needed  to  use  this  method  in  cases  of  epis- 
taxis,  and  three  or  four  times  after  extirpating  polypus,  but 
especiallv  after  using  the  knife. 

4th.  When  all  is  done  that  knife  or  forceps  can  do,  I  proceed 
to  use  the  caustic,  and  with  this  conviction,  that  I  should  be 
very  indifferent  indeed,  whether  I  destroy  the  polypus  only,  or 
the  spongy  bone,  or  much  of  the  membrane,  if  but  the  polypus 
be  destroyed.  However  confident  I  am  of  having  extirpated 
the  tumours  by  my  preliminary  operations,  I  never  think  it 
superfluous  to  burn  the  roots,  but  apply  the  caustic  the  more 
boldlv,  when,  bv  the  frequency  of  my  operations,  I  am  sure  of 
being  able  to  mark  the  points  of  the  nostril  at  which  I  have  to 
expect  the  roots  of  the  polypi.  To  apply  the  caustic  effectual- 
ly, you  must  apply  it  boldly ;  and  if  you  consider  the  important 
object  to  be  attained,  you  will  be  careless  although  it  should  af- 
fect the  spongy  bones  ;  or  rather,  you  will  be  fearless  of  every 
thing,  but  the  error  of  not  applying  it  effectually.  I  find  much 
address  necessarv  in  this,  which  I  confess  I  have  learnt  slowly. 

I  alter  my  method  occasionally,  in  the  course  of  a  cure,  and 
according  to  the  circumstances  of  each  case.  First,  I  am  care- 
ful to  have  the  nostril  entirely  cleared  of  mucus,  which,  in  the 
inflamed  state  of  the  fauces,  and  especially  after  the  operation 
of  the  caustic  is  begun,  is  secreted  in  such  profusion  as  almost 
to  suffocate  the  patient :  he  draws  much  back  into  the  throat,  he 
drives  much  outward  by  blowing  the  nose,  and  I  clear  out  the 
nostril  effectually  with  the  probe  rolled  in  lint,  and  then  the  nos- 
tril, raw  and  red  with  the  violence  it  has  sustained,  is  so  clearly 
seen  that  I  have  often  perceived,  upon  looking  into  it,  a  bud  or 


Of  small  and  incipient  Polypi.  437 

germ  of  the  polvpus  still  remaining,  though  very  deep  in  the 
nostril,  and  very  small.  But  independent  of  this  process  of 
clearing  and  inspecting  the  nostril,  we  are  able,  merely  from 
calculating  the  depth  and  distance  of  the  upper  spongy  bones, 
and  recollecting  the  circumstances  of  the  operation,  to  apply 
the  caustic  to  the  roots  of  the  tumour  with  much  confidence  ; 
no  dismal  consequences  have  I  ever  witnessed,  nor  even  the 
slightest  inconveniences  from  its  being  misapplied. 

I  never  have  used  a  pencil  caustic*  in  a  port-crayon  ;  that, 
I  know,  would  be,  extremely  dangerous,  but  spread  the  caustic 
upon  lint;   (I  at  first  spread  Fig.  13. 

it  upon  leather)  as  I  would 
for  making  a  common  caus- 
tic issue.  First,  I  fold  a 
piece  of  lint  twice  or  thrice, 
and  give  it  a  triangular 
form,  (fig.  13)  and  after 
pounding  the  caustic,  I 
mix  it  with  water  into  a 
paste,  and  spread  it  in  the 
form  and  dimensions  (a) 

upon  the  lint,  and  then  bend  the  lint  over  the  point  of  a  probe,  or 
of  a  directory  rather,  the  big  obtuse  point  of  which  carries  it.  and 
deposits  upon  the  precise  point  you  wish,  fairly  and  without  get- 
ting entangled  in  it.  In  passing  so  big  a  caustic  along  the  nostril, 
the  parts  would  be  cruelly  excoriated,  were  we  not  careful  to  guard 
the  canal,  which  I  do,  by  cutting  a  stripe  of  sheep's  leather,  and 
conveying  it  high  into  the  nostril  with  the  probe,  and  laying  it 
flat  and  smooth  along  the  surface  to  be  cauterised.  I  leave  it 
there,  and  turning  the  caustic  towards  it,  I  run  ft'  up  to  the  point 
I  design  to  burn.  Upon  the  slightest  sense  of  disappointment 
I  withdraw  both,  and  begin  anew  ;  but  being  conscious  that  I 
have  succeeded,  I  withdraw  the  sheath  of  leather  at  the  same 
moment  that  I  push  up  the  caustic  to  the  part,  and  I  impress 
the  caustic  very  firmly  upon  the  part ;  for,  the  instant  it  touches 
the  naked  surface,  the  eyes  fill  with  tears,  the  patient  draws  a 
long  breath,  and  sneezes  tremendously,  and  instantly  displaces 


*  i  find,  in  looking  over  my  notes  of  cafes,  that  this  is  not  quite  corredt  ; 
that  when  I  firft  began  to  ufe  the  cauftic,  I  ufed  it  by  foaking  a  large  piece  of 
camel's  hair  pencil  in  it,  conveying  the  brufh  along  a  canulamade  ol  a  playing- 
card  ;  but  finding  fuch  application  quite  ineffectual,  and  having  also  thought  of 
ufing  a  port-crayon,  perhaps  I  may  have  tried  it,  but  I  even, in  this  firft  cafe,  re- 
newed the  ufe  of  it,  and  betook  myfelf  to  the  fcraped  cauftic,  which  being  laid 
thick,  is  equivalent  to  a  folid  cauftic,  and  yet  absolutely  fafe. 


438  Of  small  and  incipient  Polypi. 

it:  but  if  you  press  firmly,  this  irritation  goes  off  ;  if  you  have 
passed  it  far  beyound  the  strait  of  the  nostril,  and  up  to  that  point 
where  always  I  conceive  the  roots  of  the  tumour  to  lie,  it  sel- 
dom is  driven  away  by  any  future  paroxysm  of  sneezing.  It 
does  sometimes  happen,  that  the  proiuse  secretion  of  inucus 
carries  it  down,  and  the  operation  being  performtd  at  ten  o'clock, 
for  example,  the  caustic  is  discharged  by  two  or  three  o'clock  ; 
but  of:en  I  have  found  the  caustic  in  both  nostrils  next  day  at 
dressing.  It  will  add  to  your  assurance  and  confidence  when 
I  tell  you,  that  deep  as  you  may  appear  to  yourselt  to  have  in- 
troduced the  caustic  rather  beyond  the  nostril  as  you  would 
imagine,  and  on  the  very  verge  of  its  posterior  opening,  jast 
over  the  palate,  it  never  falls  backwards  into  the  throat,  nor 
ever  is  swallowed  ;  ol  the  many  hundred  times  I  have  used  the 
caustic,  no  such  thing  has  ever  happened.* 

There  is  one  thing  perhaps  contributes  to  its  coming  always 
forward,  viz-  that  the   moment  the  caustic  is  placed,  and  the 
sneezng  is  over,  I  instantly  cram  the  nostril  full  of  little   dossils 
of  lint,  which  are   lying  read\  prepared  and  are  quickly  handed 
to  me  ;  if  this  be  not  done  first,  the  nostril  and  upper   lip  are 
severely  excoriated  and  deeply  corroded  with  the  caustic;  se- 
condly, the  caustic  piece  of  cfrarpie,  if  not   supported  by  others 
from  behind,  is  apt  to  be  displaced  ;  the  nostril  being  enlarged 
by  the  polypus,  requires  a  great   deal  of  lint   to  fill  it ;    and    to 
prevent  any   drop  of  melted  caustic  or   mucus  descending  this 
way,  I  ram  the  lint  hard  into  the  nostril  at  each  dressing.       I 
find  the  lower  dossils  of  lint  discharged,  (those  I  mean,  which 
fill  the  cartilarginous  mouth  of  the  nostril)  the   caustic   ones  of- 
ten are  returned  (they   occupying  the  deeper,  straiter,   and  bo- 
ny part  of  the    nostril,  beyond  the  narrow  slit  formed  by  the 
nasal  and  spongy  bones.)     The  dossils  and  muscus  are  hooked 
out,  the  mucus  picked  away  and   sometimes  the  nostril  washed 
with  barley-water  or  oxvmel  at  each    dressing.     The  caustic  I 
apply  every  second  or  third   day  ;  I  often  continue  this   severe 
process  during  a   whole  month,    with  occasional  intermissions  : 
and  I  confess  the  whole  cure  to  be  so  difficult,  that  whether  from 
the  presenting  of  polypi  already  existing,  or  from  the  quick  re- 
generation ol  those   already  extirpated,  I  have  had  occasion, 
even  while  using  the  caustic,  to  repeat   my   incisions  with  the 
knife  :  and  while  I  am  making  incisions  upon  the  remains  of 


*  It  was  long  before  I  was  entirely  void  of  anxiety  on  this  fubject  ;  I  find  in 
my  notes,  a  cafe  of  a  young  lady  of  19  years  of  age,  who  is  now  in  perfedt  health 
that  in  phce  of  ufing  Amply  this  pledget  of  charpie,  coated  with  caullic,  I  mount- 
ed the  lint  upon  a  cone  offtiff  paper,  or  card,  the  conical  form  of  it,  the  apex 
looking  forwards  would,  I  expected,  prevent  the  cauftic  from  pafling  backwards, 
into  the  fauces.    I  did  not  then  know  how  fuperfluous  fuch  precaution  was. 


Of  large  and  guttural  Polypi.  439 

the  polypi,  or  consuming  their  roots  with  caustic,  I  find  it  ad- 
vantageous to  clear  the  nostril,  especially  in  its  back  parts,  by 
methods  almost  approaching  to  rudeness,  by  wrapping  a  big 
iron  probe,  of  a  curved  form,  round  with  lint,  or  mounting  it 
with  a  sponge,  and  running  it  thus  guarded  down  the  nostril: 
I  make  it  so  large  as  not  only  to  fill  the  nostril,  but  to  pass 
through  it  with  great  difficulty,  and  by  forcing  it  through  the 
slit  o!  the  nostrils,  quite  back  to  the  palate,  I  often  force  off 
these  remains  of  polypi,  which  are  already  halt  consumed,  or 
imperfectly  cut.*  These,  gentlemen,  are  the  methods  wh'u  h, 
used  with  perstverence  and  courage,  have  seldom  failed  me: 
of  many  patients  whom  I  have  treated,  there  are  very  few,  I 
declare  solemnly,  who  have  returned  to  put  themselves  under 
my  care:  of  the  entire  recovery  of  such  as  I  have  not  seen 
again,  it  would  be  presumption  to  speak  confidently,  but  from 
many  I  have  had  the  happiest  assurances  of  their  continuing  in 
perfect  health.  Such  is  my  process  with  the  solter,  smaller, 
and  incipient  pol\  pi,  which  occupy  only  the  nostrils,  and  are 
pronounced  mild  and  benign  :f  the  hard  and  bulky  polvpi,  pass- 
ing down  into  the  throat,  require  other  operations  ;  and  to  ex- 
plain these,  demands  a  more  methodical  enumeration  of  the 
various  inventions,  and,  I  may  say,  cruelties,  of  the  older  sur- 
geons. 

SECTION    II. 

Second  Stage  of  Polypus. 

The  fears  of  the  surgeon  increase  in  proportion  to  the  size 
of  the  polypus,  and  there  is  no  task  from  w  hich  he  revolts  so 
much,  as  that  of  grappling  with  a  polypus  which  already  de- 
presses  the    palate,    and  begins  to  fill  the  fauces  and  throat. 

*  I  fee  occafionally  the  half-confumed  polypus,  or  rather  the  root  of  it,  of  a 
very  florid  red  colour,  and  touching  it  with  (he  probe,  I  (eel  it  hard  and  granu- 
lated :  fometimes  the  opening  of  the  noitril  is  fa  cxulcerated  as  to  require  inter- 
miflion  of  the  procefs,  and  the  anointing  of  the  excoriated  parts  with  oil  or  oint- 
ments. 

f  I  fhould  be  forry  to  omit  mentioning  an  operation,  which  has  been  approved 
and  commended  by  the  greateft  pra&itioners,  and  has  held  its  place  from  me  ear- 
lieil  times;  it  was  invented,  I  believe,  by  the  Arabians;  is  deicril>ed  by  Albu- 
cafis,  and  was  ufed  fuccefstully  by  La  Faye,  in  the  Hotel  Dicu  it  i->  the  palling 
a  large  feton  or  cord  Irom  the  mouth  through  the  noftril-,  knotted,  at  interval* 
of  an  inch  or  more  ;  the  knots  are  meant  to  prefs  upon  the  roots  oi  the  polypus, 
and  made  larger,  and  drawn  up  tighter,  in  pioportion  as  the  tumour  yields,  or 
the  paflage  dilates  1  he  methanifm  of  this  invention  is  eafily  undtrftood  by  thofe 
general  tern's,  aud  I  am  not  entitled  to  be  particular,  as  no  occafion  has  prefented 
itfelf,  in  whuh  I  thought  of  ufing  this  method ;  but  it  is  furely  worthy  of  being 
mentioned,  and  1  can  imagine  a  variety  of  circumitanccs  in  which  it  may  b 
iul. 


440  Of  large  and  guttural  Polypi. 

Such  a  tumour  left  to  itself,  is  indeed  full  of  danger ;  the  nos- 
trils and  throat  are  filled  with  its  bulk,  the  bones  sorely  com- 
pressed, as  the  pain  and  stupor  sufficiently  evince ;  the  voice 
affected  ;  the  hearing  injured  ;  the  breathing  and  swallowing  in- 
terrupted ;  the  patient  is  thence  in  the  utmost  jeopardy,  and 
that  stage  fast  approaching  which  is  so  incurable.  But  this 
bulk,  which  threatens  destruction  to  the  bones,  facilitates  all 
the  surgeon's  operations,  and  is  a  probable  sign  of  the  tumour 
being  single. 

Surgery  was  at  one  period  rude  and  cruel  in  all  its  operations, 
but  those  used  for  the  extirpation  of  polypus,  were  so  in  a  pecu- 
liar degree.  The  larger  polypi,  depressing  the  palate  and  ex- 
tending towards  the  throat,  seemed  to  the  ancient  surgeons  to 
vindicate  every  degree  of  violence.  They  attempted  the  extir- 
pation, sometimes  by  the  most  cru;l  cauteries,  oftener  by  main 
force.  They,  if  the  polypus  was  long  and  pendulous,  tugged  at 
it  with  merciless  rudeness ;  if  beyond  their  grasp,  they  consumed 
it  with  heated  irons.* 

But  of  all  the  examples  of  successful  violence  upon  record, 
none  is  so  well  calculated  to  shew  what  the  parts  will  suffer,  to 
banish  all  fears  of  endangering  the  brain  by  violence  done  to 
the  spongy  bones,  while  extracting  polypi  with  forceps,  as  that 
which  I  am  now  to  lay  before  you.  It  will  at  once  suggest  ma- 
ny practical  reflections,  and  teach  you  much  of  what  you  ought 
to  know  familiarly,  concerning  the  relation  of  the  tumour  to  the 
passages  of  the  nose  and  throat. 

Mr.  Manne,  a  respectable  surgeon  of  Avignon,  was  the  ope- 
rator, and  he  related  the  case  in  a  small  volume,  published  at 
Avignon,  anno  1747:  not  contented  with  the  ordinary  means 
of  extracting  the  polypus,  finding  even  the  strongest  crow-bill 
forceps  unavailing,  he  transfixed  a  large  and  cartilaginous  tu- 
mour with  many  ligatures,  each  of  which  successively  he  twist- 
ed round  the  body  of  it,  and  with  the  help  of  these,  used  like 
a  halter,  and  by  pulling  upon  the  projecting  part  of  the  tumour, 
and  pushing  at  the  same  time  that  part  of  it  which  he  could 
reach  by  introducing  the  fingers  into  the  throat,  he  delivered 
the  patient  of  an  enormous  massy  polypus,  which,  in  bolting 
through  the  nostril,  made  a  noise  like  that  of  uncorking  a  bot- 
tle. The  patient,  from  confusion,  pain,  and  loss  of  blood, 
fainted;  while  the  numerous  assistants  were  left  in  a  degree  of 

•  This  method  of  deftroying  polypi  by  cauteries,  little  ufed  by  modern  fur- 
geons,  was  univerfally  employed  in  thole  times  when  lire  fuperleded  blifters,  fctons, 
ifl'ues,  incifions!  and  nothing  but  fire  was  ufed  for  headachs,  white  fwellings,  hae- 
morrhagies,  rheumatifms,  tumours !  Whatever,  in  fhort,  was  to  be  done,  which 
could  not  be  done  by  inciiion,  was  (to  ufe  the  words  of  Hippocrates)  "to  be 
done  by  fire." 


Of  large  and  guttural  Polypi.  44  f. 

astonishment,  from  which  they  did  not  soon  recover:  butthr-se. 
with  many  other  points,  you  will  best  learn  from  the  narrative 
of  Mr   Manne,  which  is  very  perspicuous, 

"  Etienne  Ducres,  a  villager  of  the  Duke  de  Gadagne,  se- 
venteen years  of  age,  born  in  the  village  of  Saint  Saturnine,  in 
the  Comptit,  was  attacked,  in  the  year  1745,  with  a  violent 
hemorrhage  of  the  nose  and  throat,  occasioned  bv  extreme 
heat,  from  the  direct  rays  of  the  sun  striking  upon  his  head 
during  the  labours  of  the  harvest.  During  months  the  ha> 
morrhagv  returned  from  time  to  time.  The  rheum,  and  stop- 
page of  the  passage,  which  followed  this,  shewed  the  thicken- 
ing of  the  membranes  and  glands,  and  soon  alter  the  patient 
began  to  snivel  through  the  nose  :  the  passage  was  daily  more 
and  more  obstructed  ;  he  was  no  longer  able  to  breathe  through 
the  left  nostril,  which  proved  the  existence  of  a  tumour. 

"  He  now  betook  himself  to  Avignon,  and  there  consulted 
a  surgeon,  who,  though  he  found  an  incipient  polypus  in  the 
nostril,  found  nothing,  at  that  time,  wrong  in  the  throat:  he 
pronounced  the  heats  of  the  autumnal  season,  to  be  very  unfa- 
vourable to  any  operation,  This  unhappy  delay  gave  occasion 
to  such  a  growth  of  the  pol\  pus,  that  in  the  space  of  a  few 
months,  it  had  not  only  filled  the  cavity  of  the  nose,  but  protrud- 
ed backwards  into  the  throat,  and  forwards  through  the  nostril. 

u  The  patient,  alarmed  by  this  sudden  growth,  had  once 
more  recourse  to  his  surgeon,  who  now  attempted  the  opera- 
tion ;  and  holding  the  mouth  open  with  a  speculum  oris,  he 
tried  to  twist  and  tear  away  the  polypus  from  the  throat,  with 
crow-bill  forceps,  and  pincers  of  various  forms  ;  but  .succeeded 
so  ill  as  to  tear  awav  only  (me  morsel,  the  size  of  a  peach-stone. 

11  Wearied  with  this  fruitless  labour,  he  was  willing  to  try, 
whether  he  could  not  obtain  a  better  hold  on  the  polypus  hang- 
ing out  of  the  nostril  ;  but  at  the  first  pressure  of  his  forceps, 
there  came  on  a  hamiorrhagy  so  alarming,  both  to  the  surgeon, 
and  to  all  who  assisted  at  the  operation,  that  their  work  was 
instantly  suspended  :  yet  they  made  four  more  attempts  of  the 
same  kind,  within  the  eight  succeeding  days,  and  at  each  time 
were  alarmed  with  the  same  hamiorrhagy,  and  obliged  to  de- 
sist. From  the  time  in  which  these  fruitless  operations  were 
altogether  abandoned,  the  patient  suffered  periodical  haemorr- 
hagies  ;  sometimes  from  the  throat,  (issuing  from  the  lacerated 
endof  thepolvpus)  sometimes  from  the  nose,  (where  also  it  had 
been  torn  and  mangled  with  the  forceps)  and  often  he  bled  from 
both  nose  and  throat,  the  polypus  growing  incessantly,  so  as  to 
burst  up  the  bones  of  the  nose. 

"  After  the  attempts  just  mentioned,  there  came  a  violent 
inflammation  and  abscess  of  one  side  of  the  fare  :  the  skin  sup- 

3  K 


442  Of  large  and  guttural  Polypi. 

purated  ;  the  cartilage  of  the  wing  of  the  nose  was  ulcerated 
and  opened  ;  the  suppuration,  and  all  its  consequences,  in- 
creased daily  for  two  months,  and  at  last  ceased  ;  and  then  the 
patient  fell  again  into  his  old  disorder  of  periodical  ha-morr- 
hagies,  the  blood  issuing  chiefly  from  the  nostril,  by  the  side 
of  the  polypus,  and  through  a  fistulous  opening  on  the  cheek 
near  the  nose. 

"  In  this  desperate  and  most  deplorable  situation,  the  pa- 
tient addressed  himself  once  more  to  his  surgeon,  requesting 
his  help.  But  this  gentleman,  unwilling  to  risk  his  reputation 
further  in  so  hopeless  a  case,  contented  himself  with  prescrib- 
ing some  cathartic  powders.  The  patient  knew  well  that  this 
was  but  an  apology  for  leaving  him  to  his  fate,  was  anxious  to 
find  some  one  resolute  enough  to  do  him  good,  and  lighted 
happily  on  Mr.  Manne. 

"  When  this  patient  came  to  me,  (says  Mr.  Manne)  I  con- 
versed with  him,  consoled  him,  supported  his  hopes,  and  his 
courage  ;  and  after  some  restoratives,  and  general  remedies, 
undertook  the  operation  in  my  own  house,  on  the  25th  of  Oc- 
tober, j747,  two  years  alter  the  commencement  of  the  disease, 
in  presence  of  fifty  gentlemen  of  the  profession.  I  did  not 
choose  to  have  so  particular  a  case  reported  only  on  my  own 
testimony,  or  on  that  of  a  few  partial  friends. 

"  In  the  presence  then  of  this  respectable  company,  I  began 
my  operations,  without  having  recourse  to  the  gag,  or  the  spe- 
culum oris,  used  in  the  former  operations  :  I  placed  the  pa- 
tient opposite  to  a  window  ;  and  reclining  his  head  a  little  back- 
wards, I  intreated  him  to  open  his  mouth  wide,  which  he  did 
very  courageously  ;  I  then  took  a  crooked  bistoury,  passed  it 
betwixt  the  velum  pendulum  and  the  tumour,  and  slit  up  the 
velum  from  the  side  of  the  uvula  to  the  palate  bones,  and  pro- 
ceeded then  to  the  tumour  itself,  which  was  wedged  in  the 
throat.  It  was  so  firm,  that  it  resisted  the  knife,  as  the  attend- 
ants will  testify,  who  cannot  but  remember  the  quantities  of 
blood  that  flowed  after  each  incision.  The  moment  I  began  an 
incision,  the  flood  of  blood  suffocating  the  patient  forced  me  to 
desist  ;  when  it  ceased  I  renewed  my  attempt,  only  to  be  inter- 
rupted by  a  new  hamorrhagy  :  till  at  last,  at  each  incision,  in 
consequence  of  the  hamorrhagy  that  ensued,  the  patient  fainted, 
so  that  we  were  obliged  to  allow  long  intervals  after  each  stroke 
of  the  bistoury,  lest  the  patient  should  actually  expire. 

"  The  assistants  were  cai-eiul  during  all  this  time  to  support 
the  patient  with  spirituous  liquor,  and  occasionally  spoonfuls 
of  nourishing  soups  ;  and  thus  from  incision  to  incision,  from  ■ 
hamorrhagy  to  hamorrhagy,  after  many  paroxysms  of  faint- 
ings,  did  I,  at  last,  partly  by  the  knife,  partly  by  tearing,  se- 


Of  large  and  guttural  Polypi.  443 

parate  completely  this  mass  of  tumour,  which  lay  in  the  throat, 
and  which  I  immediately  delivered  to  the  bye-standers,  that 
they  might  examine  its  extreme  firmness  and  semi-cartilaginous 
nature.  The  patient,  restored  as  it  were  from  death  to  life,  had 
still  sufficient  strength  to  walk  from  my  house  to  the  suburbs, 
where  he  lodged,  when  he  was  presently  put  to  bed,  and  proper 
diet  and  regimen  prescribed. 

"  It  was  not  fit  that  we  should  comply  with  the  spirited  and 
resolute  request  of  this  young  man,  who  besought  us  to  finish  our 
operations,  and  deliver  him  at  once,  of  whatever  remained  of 
the  tumour.  I  thought  it  prudent  to  allow  at  least  a  few  days 
of  rest  and  nourishment,  to  repair  this  loss  of  blood. 

"  After  three  days  the  slight  fever  excited  by  the  operation  hav- 
ing subsided,  and  his  strength  seemingly  recruited,  I  resolved  to 
begin  my  operations  anew.  This  was  in  October,  1747:  I 
placed  the  patient  with  his  back  resting  firm,  and  his  head  re- 
clined and  fixed ;  I  knew  too  well  the  firm  and  cartilaginous 
nature  of  this  tumour,  to  think  of  extracting  it  with  forceps, 
which  would  but  tear  it  into  morsels,  leaving  perhaps,  after  the 
laceration  of  the  nasal  portion,  and  of  that  which  hung  back- 
wards in  the  throat  an  intermediate  part,  which  would  still  ob- 
struct the  nostrils,  and  occasion  endless  operations.  I  saw  the 
nostril  besides,  too  completely  filled  with  this  polypus,  to  ad- 
mit my  forceps,  and  the  polvpus  itself  too  firm  to  be  grasped  in 
them  :  I  had  experience  sufficient  moreover  of  the  partial  and 
imperfect  success  of  the  forceps,  in  the  case  of  Jaques  Grenau  ; 
I  therefore  resolved  upon  a  more  decisive,  and  more  direct  me- 
thod of  unrooting  the  whole  at  one  pull. 

"With  this  design,  taking  in  my  hand  a  needle  remarkably 
curved,  threaded  with  a  strong  waxed  ligature,  I  transfixed  the 
polypus  as  far  hack  in  the  nostril  as  possible  :  I  then  cut  the  nee- 
dle away  from  the  ligature,  and  (the  ligature  being  double)  I 
took  first  the  two  lower  ends,  and  tied  them  firm  round  the 
lower  part  of  the  tumour,  and  the  two  upper  ends  I  tied  in  lik^ 
manner  round  its  upper  part,  and  then  taking  one  end  of  each, 
viz.  of  the  upper  and  lower  ligature,  I  twisted  them  on  one 
side,  I  tied  and  twisted  the  two  other  ends  of  the  opposite  side, 
and  thus  having  transfixed  the  centre  of  the  polvpus,  and  twist- 
ed these  numeroas  ligatures  round  the  sides  of  it,  I  had  got  a 
hold  which  could  not  slip :  I  grasped  the  four  ligatures,  twisted 
them  into  one,  and  pulling  by  this  hold,  I  brought  the  polypus 
so  low,  that  not  merely  the  part  thus  transfixed  with  the  crook- 
ed needle,  but  half  an  inch  more  of  the  polypus  appeared  with- 
out the  nostril.  I  took  now  a  second  crooked  needle,  trans- 
fixed the  polypus  with  a  second  double  li  j.iture,  like  the  first, 
tied  and  knotted  it  in  like  manner,  and  having  thus  got  a  firmer 


4-44  jf  large  and  guttural  Poly ju. 

purchase,  I  twisted  the  four  ends  of  this  ligature  along  with 
the  first,  round  the  tumour  ;  and  now  shaking  the  whole  mass 
of  the  polypus  from  side  to  side,  thi  n  moving  it  with  a  rotatory 
motion,  then  pulling  from  right  to  left,  and  next  reversing  that 
motion,  by  moving  the  mass  from  left  to  right;  in  short,  by 
moving  and  shaking  the  polypus  in  every  possible  direction,  I 
sought  to  disengage  it  Irom  its  connections,  pulling  towards  me 
always  with  such  strength,  as  to  make  the  tumour  follow  every 
lateral  motion,  and  yet  with  such  a  measured  force,  as  to  pre- 
vent the  ligatures  breaking;  for  had  that  unfortunately  happened, 
the  tumour  itself  would  have  receded  into  the  nostril,  while  a 
fragment  only  would  have  remained  in  my  hand. 

u  By  successive  and  regulated  efforts,  I  so  far  succeeded,  as 
to  elongate  the  tumour  still  more;  an  inch  more  of  its  length 
appeared  without  the  nostril ;  I  struck  a  third  double  ligature 
through  the  polypus,  which  I  twisted  as  formerly,  and  added 
to  the  others ;  and  with  this  new  purchase,  I  pulled  so  success- 
fully as  to  elongate  the  tumour  still  more  ;  and  transfixing  it 
again  with  a  fourth  ligature,  as  deep  as  possible  within  the  nos- 
tril, I  obtained,  by  pulling  with  the  whole  sixteen  ligatures,  in- 
conceivable power  and  purchase. 

n  I  was  now  on  the  point  of  extracting  the  polvpus  by  the 
roots ;  and  by  the  happiest  chance  observed  a  trifling  circum- 
stance (for  the  most  trivial  circumstances  are,  in  the  critical  mo- 
ment ol  an  operation,  of  the  very  last  importance)  which  con- 
tributed greatly  to  my  success  :  having  introduced  two  of  the 
fingers  of  mv  lett  hand  crooked,  into  the  throat,  to  feel  whe- 
ther the  hold  I  had  upon  the  nasal  branch  of  the  pohpus  af- 
fected that  within  the  fauces,  and  whether  the  guttural  part  of 
the  polspus  was  of  such  a  form  as  to  pass  easily  back  again 
through  the  opening  from  the  throat  to  the  nostrils,  so  as  to 
follow  the  nasal  br  nch  when  it  was  extracted,  I  felt  distinctly, 
that  b\  pulling  the  ligature  which  surrounded  the  nasal  branch 
of  the  polypus,  I  not  only  moved  at  each  pull,  the  branch  which 
hung  down  into  the  throat,  but  also  was  sensible  that  this  lower 
branch  (the  branch  which  I  had  formerly  cut  with  the  bistoury) 
consisted  of  two  tubercles  or  heads,  greatly  exceeding  in  size 
the  posterior  opening  of  the  nostrils.  With  mv  fingers  of  the 
right  hand,  twisted  among  the  ligatures  surrounding  the  nasal 
branch,  I  pulled  upon  it  ;  while  with  the  fingers  of  my  left 
hand,  thrust  into  the  throat,  I  pushed  back  towards  the  poste- 
rior opening  of  the  nostril,  the  tubercle  which  was  nearest  to 
it;  then  by  a  second  effort  of  the  same  kind,  I  forced  the  se- 
cond tubercle  to  follow  the  first;  and  being  sensible  that  both 
were  fairly  entered  into  the  passage  of  the  nostril,  I  continued 
to  thrust  with  the  fingers  of  the  one  hand  against  the  guttural 


Of  large  and  guttural  Polypi.  445 

part  of  the  polypus,  pulled  with  the  other  upon  the  nasal  branch, 
and  redoubling  my  efforts,  and  increasing  the  force,  in  propor- 
tion to  the  progress  of  the  polypus,  it,  alter  much  struggling, 
and  many  repeated  endeavours,  bolted  (alter  one  final  effort) 
so  suddenly  out  of  the  nostril,  that  the  noise  was  like  that  of 
uncorking  a  bottle. 

4-  The  moment  the  polypus  was  torn  away,  you  would  have 
thought  the  patient  would  have  expired,  the  blood  bursting  out 
in  a  full  flood  from  nose  and  mouth  ;  but  as  the  blood  burst 
out  thus  suddenly,  it  ceased  instantaneously  ;  for  it  proceed- 
ed chiefly  from  the  vessels  of  the  polvpus  distended  b\  the 
compression,  which  were  no  sooner  emptied  than  they  ceased 
to  bleed. 

"  The  spectators  did  not  soon  recover  the  amazement  with 
which  they  were  struck  at  seeing  so  enormous  a  mass  of  tumour 
issue  from  so  narrow  a  passage.  This  polypus  was  covered 
with  a  membrane,  very  white,  smooth  and  polished,  with  an 
infinity  of  small  vessels  circling  upon  its  surface  ;  and  its  sur- 
face was  dotted  with  an  infinite  number  of  bloody  points,  red 
with  drops  of  blood,  denoting  the  manner  in  which  it  had  ad- 
hered to  the  pituitary  membrane. 

"  No  sooner  was  the  lad  delivered  of  the  polypus,  than  he 
straightway  breathed  through  that  nostril  freely,  and  was  as 
suddenly  relieved  of  an  insupportable  head-ach,  with  which  he 
had  been  night  and  day  tormented  for  more  than  a  year,  He 
recovered  his  sense  of  smelling  ;  but  what  is  more  singular,  he 
recovered  at  the  same  time  the  sense  of  tasting,  which  he  had 
entirely  lost.  After  this  second  operation  we  washed  out  the 
passages  with  detersive  and  vulnerary  injections,  to  which  spi- 
rituous tinctures  were  necessarily  added,  to  correct  the  putri- 
dity of  the  foul  and  very  fetid  sanies,  which,  by  its  horrible 
fetor,  declared  the  disorder  of  the  parts  produced  by  this  tedi- 
ous disease,  and  the  recent  violence  done  to  them. 

"  Yet  the  patient  was  in  perfect  health,  weakness  excepted  : 
he  was  free  from  fever :  he  slept  as  if  he  would  never  awake  ; 
and  when  he  rose  it  was  with  the  appetite  of  a  famished  crea- 
ture, ravenous  for  food.  But  the  attendants  were  inexorable, 
and  never  permitted  him  to  exceed  the  diet  prescribed  for  him. 
"Two  days,  and  no  more,  had  passed,  when  the  patient,  all 
at  once  observed,  that  he  had  no  longer  that  perfect  freedom 
in  swallowing  and  breathing,  which  the  operation  had  restored 
him  to  so  suddenlv.  He  was  sensible  of  a  new  obstruction  in 
the  throat,  little  differing  from  that  which  he  had  so  long  en- 
dured :  I  visited  him  on  occasion  of  these  new  symptoms,  and 
I  will  ingenuously  confess,  that  if  I  was  astonished  at  the  size 
and  nature  of  the  first  polypus,  my  surprise  was  inexpressible, 


446  Of  large  and  guttural  Polypi. 

when  I  found  the  throat  choaked  anew,  with  a  polypus  of  such 
enormous  size,  that  it  seemed  as  if  not  a  particle  oi  the  first 
had  been  actually  destroyed.  I,  without  loss  of  time,  con- 
voked the  ph\sicians  and  surgeons  who  had  witnessed  the  first 
operation.  They  were,  I  believe,  not  a  little  astonished  to  see, 
apparently,  the  individual  polypus  which  they  themselves  had 
assisted  to  extract,  re-occupying  its  proper  place.  Curiosity 
led  us  to  examine  how  this  could  be,  and  no  conjecture  seemed 
more  probable  than  that  this  new  polypus  had  fallen  down  from 
the  upper  and  back  part  of  the  nostrils,  where  it  had  been 
squeezed  up  by  the  former  polypus,  and  nitched  in  the  narrow 
cavity :  the  extirpation  of  the  former,  it  would  appear,  had 
made  way  for  this  falling  down. 

"  I  did  not  long  hesitate  how  to  act,  but  waited  only  the  re- 
turn of  my  patient's  strength,  to  cut  off  this  polypus  also:  for 
I  was  afraid,  in  his  present  weakness,  of  the  haemorrhagies  in- 
separable from  such  operations.  I  allowed  however  only  six 
days  to  pass  over,  when  convoking  the  same  surgeons  who  had 
assisted  me  at  the  former  operation,  I,  in  their  presence,  on 
the  third  of  November,  cut  out  from  the  throat,  a  portion  or 
knob  of  the  new  polypus,  represented  in  the  drawing,  which  I 
accomplished  now  with  much  less  pain,  because  it  hung  by  two 
pedicles,  and  was  softer  than  the  former  :  the  hremorrhagy  was 
moderate,  and  nothing  to  be  compared  with  that  of  the  former 
operations. 

"  The  patient  instantly  felt  the  benefit  even  of  this  partial  ex- 
tirpation, for  the  throat  was  entirely  freed,  and  he  even  began 
to  breathe  through  the  nose  :  but  this  quiet  state  he  did  not  long 
enjoy,  for  before  morning  a  new  lobe  of  the  polypus  had  de- 
scended, occupied  the  place  of  that  just  amputated,  and  all  his 
difficulties  and  distresses  returned  with  the  tumour.  Nothing 
remained  for  me,  but  to  relieve  the  patient,  by  cutting  off  all 
the  heads  of  this  Hydra,  or  abandoning  altogether  an  operation, 
in  which  I  had  already  atchieved  so  much,  which  had  cost  my- 
self such  anxieties,  and  my  patient  so  much  pain  and  suffering. 
My  spirit  was  so  raised,  and  the  patient  himself  so  full  of  con- 
fidence and  courage,  so  well  resolved  to  submit  himself  to  what- 
ever I  thought  fit  to  do,  that  it  was  determined  to  cut  this  poly- 
pous mass  once  more,  and  to  the  quick.  But  I  had  found  such 
advantages  in  allowing  an  interval  betwixt  each  operation,  that 
I  imagined  I  could  not,  on  the  present  exigency,  act  more  pru- 
dently than  to  allow  the  patient  a  short  respite. 

"  But  while  I  was  meditating  this  new  operation,  the  singu- 
lar nature  of  the  case  drew  together  all  those,  who  had  hitherto 
in  compliment  to  me,  or  through  charity  towards  the  patient, 
watched  the  course  of  his  disease,  and,  by  perpetually  thrust- 


Of  large  and  guttural  Polypi.  447 

ing  in  their  fingers,  touching  the  polypus,  torturing  the  nostril, 
searching  in  various  ways,  some  to  ascertain  its  size,  others  to 
feel  for  its  root,  others  with  the  hopes  of  reaching  its  pedicle, 
and  disengaging  the  tumour,  without  having  further  recourse 
to  the  knife,  the  roots  were  finally  so  torn  and  lacerated,  and  the 
body  of  the  tumour  itself  was  so  compressed  and  bruised,  that 
in  a  few  davs  it  began  to  shrink  and  shrivel,  fell  into  suppura- 
tion, became  rotten  and  fetid,  and  dropt  away  piecemeal  in 
small  portions,  one  of  which  however  was  as  long  and  as  large 
as  a  thumb  :  by  this  wasting  of  the  tumour  the  patient  was 
freed  of  it  in  a  few  days,  without  the  help  of  the  knife  or 
cautery,  nor  did  I  choose  to  meddle  with  the  roots  of  the  tu- 
mour, both  because  I  thought  that  where  nature  had  done  so 
much,  it  was  wrong  to  interfere  ;  and  because  I  could  perceive 
that  the  root  or  basis  of  the  tumour  was  melting  away  slowly  of 
its  own  accord." 

Mr.  Mamie  has  added  in  his  book,  in  testimonial  of  these 
facts,  the  affidavit  of  nine  of  the  Gentlemen  who  attended  the 
operation,  and  of  Francois  Payen,  in  whose  house  the  patient 
lived. 

"  This,"  savs  Mr.  Manne,  in  concluding  the  narrative,  "  is 
a  deadly^  blow  to  the  opinion  of  those  who  believe  in  the  plurali- 
ty of  polvpi  :?' — by  no  means :  it  is  as  I  have  said,  in  the  words 
of  the  fable,  one  looking  on  the  side  of  the  statute  which  is 
white,  while  another  looks  on  that  which  is  sable.  Polypi  of 
this  magnitude  are  usually,  but  not  necessarily,  solitary. 

A  narrative  so  very  interesting  as  this,  should  not  be  dis- 
missed slightly  ;  it  suggests  various  useful  remarks  ;   it  opens 
up  to  us  much  of  the  rude  practice  which  prevailed  even  in  the 
last  century,  of  slitting  up  the  palate,  pulling  with   great  iron 
forceps,  bolting  out  the  tumour  at  the  same  time,  by  pressing  be- 
hind the  palate  with  the  fingers  ;  extracting  by  main  force  of 
pulling,  with  the  help  notunfrequently  of  a  great  crooked  knife. 
We  are  led  by  this  narrative  to  doubt  the  prognostic  handed 
down  from  the  times  of  Fabricius,  or  indeed  of  Celsus,  of  the 
soft  polypus  being  mild,  the  firm  and  hard  cancerous  !  Every 
polypus  is  soft  in  its  commencement,  firm  in  its  perfect  growth  : 
I  never  have  grappled  with  a  polypus  of  this  size,  or  anv  thing 
approaching  to  it,  which  was  not  semi-cartilaginous  and  of  a 
stony  hardness;  such  at  least  were  those  of  a  young  man  of  the 
name  of  Reid,  and  of  one  Gow,  which  I  extirpated  with  liga- 
tures ;  their  cases  I  shall  presently  mention,  for  other  purposes 
than  to  prove  this  fact.  But  surely,  if  ever  a  long  and  firm  poly- 
pus should  by  nature,  and  by  irritating  causes,  have   become 
cancerous,  this  might  have  been  so  ;  nay,  I  doubt  not,  that  in 
examining  the  records  of  our  profession,  you  will  find  those 


448  Of  large  and  guttural  Polypi. 

cartilaginous  polypi  the  most  frequently  and  effectually  cured  ; 
and  I  shall  presently  state  to  you  my  reasons,  why  I  would 
rather  grapple  with  a  b;g  polypus,  than  a  small  one  ;  rather  with 
a  tumour  that  reached  the  throat,  and  depressed  the  soft  plate, 
than  with  one  which  was  but  indistinctly  felt  in  the  nostril. 
The  latter  is  small,  delicate,  and  yields  to  the  forceps ;  the  body 
is  crusted  so  as  to  g>ve  no  hold,  while  the  neck  and  root  remain 
untouched  ;  the  latter,  in  proportion  as  it  grows  firmer  in  its 
body,  grows  smaller  in  its  neck,  or  pedicle,  its  root  cannot 
much  enlarge,  while  its  body  does ;  the  disproportion  betwixt 
the  tumour  and  its  pedicle  is  daily  increasing,  and  becoming 
more  favourable  to  all  kinds  of  operation,  whether  rude  or  skil- 
ful. The  polypus,  by  this  process,  has  been  known,  I  have 
known  it  myself,  drop  away  in  process  of  time,  as  ripe  fruit 
drops  from  the  tree. 

The  merit  of  the  operator,  in  this  singular  case,  is  least  of  all 
to  be  passed  in  silence.  The  enterprise  was  bold,  manfully 
conducted,  and  attended  with  success  every  way  gratifying. — 
Never  perhaps  was  there  a  more  desperate  situation  than  that 
of  the  patient  ;  the  face  deformed,  the  cheek  in  a  state  of  sup- 
puration, the  gristle  of  the  nose  perforated,  the  polypus  protru- 
ding through  the  opening  of  the  nostril,  filling  the  cavity  of  the 
nose,  and  extending  to  the  throat  :  the  disease  neglected  for 
two  years :  the  patient  tortured  with  pain  and  confusion  of  head, 
dying  of  h^morrhagy,  and  soliciting  the  surgeon  to  perform 
any  desperate  operation  that  might  promise  relief.  The  polypus 
of  that  firm  and  cartilaginous  texture,  which  all  writers  have 
agreed,  denotes  a  cancerous  disposition.  Even  such  a  tumour 
was  torn,  mangled,  cut,  one  way  or  other  extirpated,  and  finally 
cured  !  From  this  what  should  we  infer?  First,  that  if  there 
seem  something  of  good  fortune  in  that  perpetual  laceration, 
with  the  fingers  of  inquisitive  visitors,  by  which  the  patient  was 
ultimately  delivered  by  ulceration  of  the  polypus,  or  its  remains; 
still  it  was  that  sort  of  good  fortune  which  the  bold  and  skilful 
deserve  ;  and  next  it  leads  us  to  indulge  the  belief  that  it  is 
among  the  first  moral  duties  of  our  profession,  to  attach  our- 
selves more  faithfully  to  our  patient,  in  proportion  to  his  dan- 
ger, not  to  shrink  with  heartless  policy  from  the  ugliest  opera- 
tion his  condition  may  require.  It  is  not  because  we  are  un- 
certain of  atchicvinga  cure,  acquitting  ourselves  with  honour, 
that  we  are  to  abandon  our  patient :  where  nicer  and  more  de- 
licate operations  fail,  we  must,  at  his  request,  betake  ourselves 
to  the  more  rude  and  desperate.  It  is  not  the  barbarous  or 
cruel  manner  of  our  operation,  that  we  have  to  consider,  but  its 
tendency  to  preserve  life  :  it  is  not  by  our  feelings,  but  our  rea- 
son, that  we  are  to  be  guided  ;  else  all  great  and  important 


Of  large  and  guttural  Polypi.  449 

operations  should  be  abandoned  ;  surgeons  would  decline  ope- 
rating for  the  stone  or  even  trepanning  ;  for  these  also  manifestly 
endanger  life,  and  are  attended,  even  in  the  most  skilful  hands, 
with  circumstances  of  particular  cruelty.  You  know  now  by 
experience,  in  this  one  case  at  least,  that  operations  for  the  cure 
of  polvpi,  to  be  successful  must  be  in  some  degree  cruel  :  ope- 
rations within  the  narrow  passages  ol  the  nose  and  throat,  like 
those  of  midwifery,  where  we  are  forced  to  introduce  the  hand 
and  instruments,  require  perseverance,  even  violence  and  de- 
termined courage,  more  than  skill  or  delicacy  ;  and  in  both 
kinds  of  operations,  these  natural  passages  bear,  without  essen- 
tially suffering,  a  degree  of  violence,  which  those  unaccustomed 
with  practice  would  be  afraid  to  use.  Haemorrhages  from  the 
womb,  or  from  the  nostrils,  and  the  violence  necessary  in  ex- 
tracting a  polypus,  or  delivering  a  woman,  are  such  as  would 
terrify  a  timid  man,  and  prevent  him  from  performing  his 
most  necessary  duties  ;  whereas  to  the  man  of  experience  and 
courage,  these  considerations  are  but  an  incitement  to  do  his 
work  resolutely  and  speedily.  From  this  feeling  it  is  that  the 
fear  of  a  patient  suffocating  or  bleeding  to  death,  incites  the 
operator  ;  like  personal  danger,  he  feels  that  the  present  fate 
of  his  patient  is  in  his  hands,  he  acts  by  an  impulse  like  instinct, 
he  is  unconscious  ot  the  efforts  he  makes,  and  accomplishes 
things  during  such  a  struggle,  which,  in  cold  blood  he  could 
not  do.  This  is  the  kind  of  merit  that  the  operator  had  in  this 
singular  case. 

Often  the  methods  of  the  older  surgeons  are  so  incorrectly, 
or  at  least  so  indistinctly  related,  that  we  learn  little  more  than 
this,  that  wherever  the  polypus  was  sufficiently  large  to  pro- 
ject, they  could  never  resist  the  desire  ot  extracting  it  by  main 
force  :  they  seldom  used  the  knife,  or  even  cauterized  the 
roots  of  a  polypus.  But  Purmannus  appears  to  have  approach- 
ed to  a  better  manner  than  any  of  his  predecessors  :  for  while 
his  assistant  or  apprentice,  pulled  upon  a  great  polvpus,  which 
hung  pendulous  from  the  nose,  as  large  as  a  Muscadcl  pear,  he 
introduced  the  forceps  towards  the  root  of  the  tumour,  and 
pinched  it  off;  and  indeed  it  has  often  occurred  to  me,  that 
should  I  ever  fail  of  extirpating  by  the  ligature,  those  great 
polypi  which  tend  backwards  to  the  throat,  and  depress  the 
palate,  I  should  operate,  not  as  these  gentlemen  have  done,  by 
slitting  the  palate,  by  cutting  across  the  tumour,  when  it  ap- 
pears behind  the  palate,  or  pull  with  great  forceps  introduced 
by  the  mouth  ;  but  in  examining  the  disease  I  should,  by  feel- 
ing with  a  bent  probe,  or  various  shaped  hooks,  search  the 
nostril  for  the  root ;  if  I  could  then  hook  the  neck  of  the  tu- 
mour, so  as  visibly  to  move  the   bodv  where  it  appears  in  the 

3  L 


450  Of  large  and  guttural  Polypi. 

throat,  I  should  be  sure  of  mv  stroke,  and  proceed  with  con- 
fidence  ;  it  fixing  a  sharp  hook  into  the  tumour  behind  the  pal- 
ate, and  passing  a  blunt  one  into  the  nose,  I  could  move  the 
tumour  alternately  upwards  and  downwards,  I  should  then  be 
able,  either  by  pinching  with  the  lorceps,  to  pinch  off  the  root, 
as  Purmannus  seems  to  have  done ;  or  rather,  following  mv 
usual  method,  I  should  pass  one  ol  the  knives,  small  and  bistoury- 
shaped,  such  as  I  have  hitherto  used,  deep  into  the  nostril, 
and  cut  the  root  there  :  and  take  notice,  that  the  surgeon  who, 
in  handling  a  great  guttural  polvpus,  reaches  its  root  by  the 
nose,  is  sure  of  cutting  it  in  the  narrowest  part  of  its  neck,  close 
by  the  spongy  bone. — This  operation,  if  dexterously  perform- 
ed, would  be  speedy,  almost  painless,  and  as  effectual  as  it  the 
tumour  were  cutaneous  ;  and  the  tucmorrhagy  would  be  very 
slight  indeed,  and  easily  suppressed  by  the  plugs.  I  have  con- 
stantly observed,  that  the  haemorrhagy  which  is  dangeious  or 
fatal,  is  that  only  which  proceeds  from  the  universal  ulceration, 
and  an  extensive  surface  ;  not  that  it  proceeds  from  the  small 
root  of  a  polypus,  or  the  stroke  of  the  knife. 

There  is  yet,  among  the  practices  of  the  older  surgeons,  one 
which,  though  the  most  obsolete,  deserves,  I  think,  the  atten- 
tion of  a  practical  surgeon  in  an  especial  manner;  because  it  re- 
lates to  many  of  his  operations,  and  may,  I  think,  suggest 
occasional  me  thods  very  useful ;  it  is  an  operation  not  very  dis- 
tinctly defined,  otherwise  than  by  its  name,  which  expresses 
the  purpose  of  it,  viz.  The  Compunctio  Polypi,  or,  as  I  think  I 
have  somewhere  read  it,  Comminutio  Polypi :  it  was  a  lacerating 
or  transfixing  of  the  root  so  as  to  kill  the  body  ;  and  though  it 
seems  to  have  been  performed  according  to  no  very  regular  nor 
established  plan,  is  yet  commemorated  bv  various  authors. — 
Heister  mentions  it  in  very  brief  terms,  "  There  are  yet  several 
methods  (says  he)  of  removing  polypi  ;  those  which  are  recent 
will  sometimes  shrink  and  disappear,  by  repeated  punctura- 
tions  or  scarifications  with  a  scalpel  or  lancet,  as  Severinus 
asserts  he  has  experienced."  Hildanus  gives  the  title  De 
Compunctione  Polypi  to  his  ninth  chapter,  and  speaks  respect- 
fully of  this  operation  of  Severinus.  He  describes  it  as  an  ope- 
ration performed  by  itinerants  rather,  whose  method  was  not 
expressly  known,  than  by  regular  physicians,  and  says,  "  The 
report  goes,  that  they  tie  together  three  long  needles,  and  pla- 
cing the  head  of  the  patient  in  a  favourable  posture,  they 
scarify  the  tumour  with  the  points.  They  then  anoint  the 
punctured  part  with  oil.  No  ill  consequences  are  tound  to 
ensue  ,  the  process  is  repeated  from  day  to  day,  and  the  polypi 
shrink  and  waste  till  the  patient  is  in  a  little  while  restored  to 
perfect  health.     Such,"  says  Hildauus,  "  is  the  method  sug- 


Of  large  and  guttural  Polypi.  45  i 

jested  by  Hierocles,  a  celebrated  writer  in  the  veterinary  art. 
Nor  do  I  see  why  an  operation  so  gentle  should  not  be  transfer- 
red to  ours  r"  Nor  can  I  imagine  a  reason  against  a  practice  so 
likely  to  prove  successful ;  so  generally  believed  among  the 
older  surgeons  to  be  profitable  in  the  small  spongy  and  blood- 
less polvpi,  which  occupy  the  nostril  alone. 

It  is  reported,  that  the  method  of  killing  a  polypus  by  a  liga- 
ture, drawn  high  round  its  roots,  and  tightened  from  day  to 
day,  is  of  ancient  date.  But  though  I  willingly  commend,  and 
as  wiilingK  borrow  from  the  works  ol  the  old  surgeons,  I  find 
nothing  to  praise  in  their  manner  of  applving  the  ligature,  nor 
indeed  any  thing  but  their  boldness  and  courage,  in  grappling 
willingh  (sometimes,  it  must  be  confessed,  alter  having  bar- 
gained tor  their  thirtv  or  fifty  crowns,)  with  the  most  bulky  and 
formidable  polvpi.  Ligatures,  no  doubt,  they  did  apply  ;  but 
assuredly  they  had  no  other  design,  than  to  save  that  blood, 
which  the  patient  could  not  but  lose  when  they  cut  them  off  with 
their  bistouries.  The  design  ot  pushing  up  the  ligature  to  the 
basis  of  the  tumour,  never  entered  so  far  into  their  system  ol 
operating,  as  to  lead  them  to  think  even  of  pushing  the  loop  up 
to  the  root  with  a  forked  probe.  Glandorpius  passed  a  thread 
of  strong  silk  round  the  polypus,  drew  it  tight,  secured  it  with 
a  knot,  and  then  cut  off  the  tumour  close  to  the  ligature.  "But 
to  perform  this  operation  successfully,"  says  Heister,  "  it  will 
be  necessary  to  extract  the  pol\pus  as  far  as  you  can  out  of  the 
nose  by  pliers.  This  too  must  be  done  gradually  and  gently, 
lest  you  break  off  the  tumour  before  you  have  made  the  liga- 
ture ;  it  must  be  left  upon  the  part  <fter  your  abscission,  till  it 
is  spontaneously  digested  off  ;  and  thus  you  cure  the  disorder 
zvithout  running  the  risk  of  a  profuse  hcemorrhagy,  which  is 
sometimes  such  as  to  kill  the  patient,  especially  when  the  poly- 
pus is  removed  by  avulsion.1'  Such  were  the  purposes  of  the 
ligatures,  used  by  the  older  surgeons :  it  was  a  tourniquet, 
merely  intend-:  d  to  prevent  the  loss  of  blood  in  their  rude  ampu- 
tation of  the  tumour.  Heister  seems  to  have  had  a  conscious- 
ness of  the  imperfection  of  this  method,  and  to  have  sought  a 
more  effectual  manner  of  fixing  the  ligature.  In  the  case  of  an 
old  lady,  afflicted  with  polypus,  he  struck  his  ligature  through 
the  body  of  the  tumour  within  the  nostril,  but  far  from  the 
root. 

But  all  these  methods  were  violent  and  rude.  Seldom  did 
the  older  surgeons  affect  gentle  means :  never  indeed,  that  I 
recollect,  except  in  this  solitary  instance,  when  they  stood  in  the 
point  blank  danger  of  disgrace  from  hsemorrhagy,  when  cutting 
with  their  crooked  knives. 

They  scrupled  not  to   slit  up  the  nostrils :  and  the  cleaving 


452  Of  large  and  guttural  Polypi. 

the  palate,  with  the  first  stroke  of  their  bistoury,  from  the  uvula 
to  the  bone,  was  no  uncommon  way  of  making  room  for  cut- 
ting the  polypus  itself  at  the  second  stroke.  ll  Before  I  con- 
clude," says  Garengeot,  "  1  must  mention  to  you,  that  often 
polypi  so  entirely  obstruct  the  nostril,  as  to  prevent  the  possi- 
bility of  introducing  instruments  to  grasp  the  tumour  ;  and  in 
such  circumstances  the  surgeon  has  no  choice,  but  must  dilate 
the  nostril  with  a  cutting  instrument.  The  sole  difficulty  is  to 
know  at  what  point,  or  in  what  direction."  These  are  polite 
terms,  "  dilating  the  nostril  with  a  cutting  instrument,"  for 
slitting  it  up  with  a  bistoury  ;  and  where  the  only  difficulty  was, 
about  the  direction,  that  would  not  stand  long  in  way  of  a 
surgeon  of  this  complexion. 

Such  was  the  horror  of  surgeons  at  this  disease,  or  rather  at 
this  stage  of  it,  that  they  seem  to  have  thought  no  way  excep- 
tionable, that  afforded  the  slightest  chance  of  destroying  the 
tumour.  Petit,  Garengeot,  Dionis,  Le  Dran,  Heister,  Levret, 
and  Tulpius,  all  the  best  authors,  mention  every  possible  me- 
thod with  equal  commendation,  as  if  the  surgeon  had  no  choice 
nor  limits  in  his  operation,  but  were  to  twist,  tear,  burn,  pull, 
and  destroy,  by  whatever  methods  he  best  could,  a  part  at  least 
of  the  polypus,  if  he  could  not  unroot  the  whole.  They  were, 
you  will  find  at  all  times,  as  ready  to  slit  the  nostril,  as  to  com- 
mit any  less  remarkable  atrocity  ;  and  no  operation,  was  so  uni- 
versally applauded,  as  that  of  slitting  the  palate.  "  We  cannot," 
says  La  Faye,  "  extirpate  by  the  nostril,  polypi  which  descend 
backwards  and  depress  the  palate  ;  for  what  we  see  of  such 
polypi  in  the  nostril,  is  but  a  small  portion,  which  easily  follows 
the  body  of  the  tumour,  when  it  is  extracted  by  the  mouth ;  and 
to  extract  it  by  the  mouth,  we  must  imitate  the  manner  of 
Petit,  viz.  Jir&t,  divide  the  fleshy  palate  with  a  bistoury,  and 
then  catch  the  polypus  with  crooked  pincers  on  the  fingers." 

This  operation  of  cleaving  the  palate  they  never  shrunk  from, 
because  it  is  neither  bloody  nor  dangerous,  and  it  facilitated 
their  main  design  ;  the  consequences  they  never  reflected  on, 
which,  though  in  some  degree  distant,  are  not  less  melancholy. 
For,  whatever  the  patient,  thus  treated,  does  not  swallow  with 
grrat  precaution,  rather  by  letting  it  glide  over  his  throat,  than 
forcing  it  by  the  usual  effort,  rushes  upwards  into  his  nose  ; 
and  his  voice  resembles  that  of  one  who  had  lost  his  palate  by 
the  venereal  disease. 

To  these  rude  and  cruel  methods,  the  best  of  us  may  need 
to  have  recourse  ;  and  it  is  a  merit  to  bend  up  our  mind  to  such 
cruelties,  for  our  patient's  safety :  but  when  the  polypus  has 
attained  this  size,  and  fills  the  nose,  and  depresses  the  palate, 
its  bulk  is  peculiarly  favourable  to  the  operation  of  the  ligature  ; 


Of  large  and  guttural  Polypi.  453 

and  as  it  has  not  yet  destroyed  the  bones,  the  operation  is  al- 
most always  successful.  I  like  to  be  diffuse  in  my  descriptions 
and  charactt  r  of  diseases  :  in  my  directions  for  operating,  I  at 
least  wish  to  be  perspicuous  and  concise.  You  would  imagine 
the  apparatus  for  applying  the  noose  round  a  polypus  to  be  mul- 
tifarious and  complicated  ;  you  would  at  least  imagine  the  tubes 
and  other  instruments  of  Levret,  to  be  essentially  necessary, 
and  cannot  perhaps  at  this  moment  imagine  that  any  contri- 
vances but  what  were  extremely  ingenious,  could  be  at  all  suc- 
cessful :  it  is  quite  otherwise  :  I  have  often  tried  those  much 
reputed  instruments,  with  perfect  confidence  in  them,  and  uni- 
formly, I  concluded  with  my  fingers,  the  operation  which  I  had 
tried  in  vain  to  perform  with  this  apparatus.  The  operation  I 
am  going  to  describe  requires  address  and  courage,  byt  no  in- 
strument great  or  small  :  indeed  the  instruments  are  so  descri- 
bed, that  I  am  persuaded  those  who  write  in  praise  of  them 
never  use  them.  I  require  nothing  but  a  piece  of  fine  silver- 
wire,  and  my  fingers :  I  have  frequently  used  cat-gut,  but  al- 
ways found  it  soften,  untwist,  and  become  altogether  unmanage- 
able. Ligatures  of  wetted  thread  are  quite  flaccid,  and  difficult 
to  apply :  a  silver-wire,  of  the  size  of  a  common  harpsichord 
wire,  passes  easily  through  the  nostril,  preserves  its  looped  foim 
in  the  throat,  is  easily  cast  round  the  polypus,  and  easily  twisted, 
in  a  gentle  degree,  so  as  to  kill  without  cutting  it. 

First.  Hoiv  to  pans  the  zvire  through  the  nostril  to  the 
throat.  You  have  already  felt  the  tumour  depressing  the  pal- 
ate, and  estimated  its  size  :  you  have  repeatedly  placed  the  pa- 
tient before  you,  and  made  him  open  his  throat,  and  depressed 
his  tongue,  so  as  to  occasion  straining  and  retching,  which  un- 
folds all  the  parts,  and  shews  you  their  size  and  relations :  you 
now  place  him  before  you  opposite  to  a  light,  supported  by  as- 
sistants, resolute  to  bear  whatever  you  do,  and  reconciled  to  it 
by  seeing  that  you  have  only  a  piece  of  silver  wire  in  vour  hand. 
You  take  the  piece  of  wire,  about  three  feet  long,  double  it 
and  smooth  and  arrange  the  doubled  part,  by  pressing  and 
modelling  it  in  your  fingers  into  a  neat  noose,  a  little  open  and 
ready  to  expand  when  it  gets  into  the  throat,  but  small  enough 
to  pass  through  the  nostril  j  and  taking  this  loop  betwixt  your 
fore-finger  and  thumb,  you  enter  it  into  the  nostril,  and  push  it 
gently  along.  However  big  the  polypus,  you  find  that  the  loop 
of  silver-wire  glides  easily  and  smoothly  along  j  find  it  some- 
times stopped,  and  then  it  bends  and  resists,  but  withdraw  it  a 
■little,  and  then  push  it,  and  it  will  go  on.  I  have  never  found 
occasion  to  use  any  instrument  for  conveying  the  loop  to  the 
throat,  except  when  the  bones  were  destroyed  ;  a  case  in 
which  I  can  hardly  counsel  you  to  attempt  the  cure.     I  have 


454  Of  large  and  guttural  Polypi. 

thus  imagined,  that  the  wire  was  turned  aside  into  the  antrum 
Highmorianum,  and  have  used  a  catheter,  cut  or  open  at  the 
point  as  a  canula,  for  passing  the  wire,  and  then  pushed  on  the 
wire  till  it  could  be  seen  and  catched  in  the  throat,  and  then 
withdrawn  the  catheter. 

Second.  Hoxv  to  hook  out  the  wire  from  the  throat.  You 
cannot  be  one  moment  at  a  loss  to  know,  when  the  wire  reaches 
the  throat ;  for  while  it  passes  along  the  nostril,  it  excites  not 
even  sneezing  or  watering  of  the  eve  ;  but  the  moment  it  passts 
the  uvula,  or  touches  either  on  one  side  the  tonsils  or  the  back 
of  the  pharynx  it  excites  a  sense  of  suffocation,  and  a  desire  to 
cough,  with  sneezing,  which  the  patient  cannot  a  moment  re- 
strain. Upon  looking  down  into  the  throat,  the  loop  of  the 
wire  is  seen,  it  is  easily  hooked  out  by  a  blunt  hook,  or  catched 
with  common  dressing  forceps,  or  a  bended  probe.  Then 
quickly  push  the  wire  onwards  through  the  nostril  with  the  fin- 
ger and  thumb  of  the  left  hand,  hook  it  forward  through  the 
mouth  with  the  crooked  fore-fingers  of  the  right  hand,  and  as 
soon  as  you  have  got  the  loop  without  the  lips,  all  is  quiet 
again  ;  yet  in  all  cases  the  hooking  it  thus  is  a  painful  struggle, 
though  in  the  hands  of  a  dexterous  surgeon,  a  momentary  one. 
Often  you  will  find  the  loop  of  your  wire  passing  actually  down 
into  the  glottis  ;  the  patient  instantly  cries,  coughs,  and  strains 
violently,  while  the  face  becomes  turgid,  and  the  eyes  stand  in 
tears:  instantly,  knowing  what  kind  of  an  accident  has  hap- 
pened, you  withdraw  the  wire  a  little  towards  the  nostril ;  by 
this  motion  you  retract  it  from  within  the  glottis,  and  you  keep 
it  carefully  there  till  the  straining  ceases  ;  then  you  push  it 
gently  on  again,  keeping  the  mouth  open,  and  catching  the  wire 
the  moment  it  appears  behind  the  tonsils.  In  this  part  of  the 
operation,  there  is  much  address  and  some  practice  requisite ; 
first,  in  stealing  the  wire  on  so  gently  that  the  patient  scarcely 
feels  it;  secondly,  in  diving  keenly  and  resolutely  with  the 
finger  into  the  fauces,  the  moment  the  wire  begins  to  excite  the 
throat,  or  becomes  visible  behind  the  velum  :  and  lastly,  in 
quieting  and  composing  the  patient  for  the  next  part  oi  the  ope- 
ration, viz.  that  of  casting  the  noose. 

Third.  Of  spreading  the  loop  of  the  ruire,  and  casting  the 
loop  over  the  polypus.  You  now  draw  out  the  loop  of  wire  en- 
tirely from  the  mouth,  and  spread  it  wide ;  you  prepare  to  re- 
act with  the  right  hand,  in  favour  of  the  left ;  you  take  the  two 
ends  of  the  wire,  which  project  from  the  nostril,  firmly  in  the 
left  hand,  twisting  it  round  the  fingers  for  a  surer  hold  ;  you- 
gather  the  fingers  of  the  right  hand  together  with  the  thumb,  so 
as  to  form  a  cone,  and  taking  the  loop  of  the  wire  upon  the  co- 
nical fingers,  you,  by  drawing  the  wire  up  towards  the  nostrils. 


Of  large  amd  guttural  Polypi.  455 

tighten  the  loop  so  upon  the  fingers,  that  it  is  not  easily  dis- 
placed in  the  next  step  of  the  operation  :  you  now  prepare  for 
that  effort,  by  which  you  are  to  carry  the  loop  over  the  biggest, 
and  most  pendulous  part  of  the  tumour  ;  and  in  this  effort  you 
are  to  succeed  at  once,  or  to  fail ;  it  can  last  but  for  a  moment : 
the  patient,  while  >ou  make  this  effort,  cannot  breathe,  he  feels 
the  severe  pressure  of  your  fingers  in  his  throat,  he  is  suffocat- 
ing, struggling  at  once  for  breath,  and  striving  to  vomit ;  his 
eyes  are  staring,  and  his  visage  inflated :  you  dare  not  keep 
him  one  moment  in  this  condition  ;  you  must  act  resolutely 
and  dexterously.  Your  purpose  is  to  push  the  ligature  home 
over  the  bulk  and  body  of  the  tumour  with  the  right  hand,  while 
with  the  left  you  draw  the  ligature  backwards  towards  the  nose: 
you  first  allow  the  patient  time  to  take  breath,  and  be  composed  ; 
you  let  him  fairly  understand  what  you  design  to  do,  and  how: 
vou  prepare  yourself  by  making  the  wire  tense,  by  puliing  with 
the  left  hand,  and  fix  the  loop  by  spreading  and  distending  a 
little  the  conical  fingers  of  the  right:  you  then,  in  one  moment, 
retract  the  ligature  steadily,  but  speedily  with  the  left  hand, 
while  you  plunge  the  loop  into  the  mouth,  and  carry  it  quite 
to  the  back  of  the  throat  with  the  right.  The  tumour,  which 
in  your  previous  examinations  you  were  able  to  touch  with 
the  points  of  your  fingers,  you  are  now,  in  the  moment  of  ope- 
ration, using  every  degree  of  violence,  and  pushing  your  hand 
boldlv  and  deeper  into  the  throat,  able  to  grapple  with,  and  by 
hooking  and  grappling  with  the  points  of  your  fingers,  you  get 
it  in  some  degree  within  your  grasp  ;  and  pulling  the  bulk  of 
the  tumour  towards  you,  with  the  crooked  points  of  your  fin- 
gers, and  slipping  off  the  ligature  from  the  points  of  your  fin- 
gers by  bending  them  still  more,  you  at  once  turn  it  over  the 
lower  part  of  the  tumour  with  the  right  hand,  and  pull  the 
noose  up  towards  the  root  of  the  tumour  with  the  left. 

Fourth.  Hoxv  to  hitch  up  the  ligature  close  to  the  root. 
With  every  operator  this  must  be  a  matter  of  great  anxiety,  for 
he  has  no  sign  nor  mark  by  which  to  know,  that  the  loop  is  car- 
ried to  the  highest  possible  point,  nor  any  sure  means  of  doing 
so.  Do  not  let  me  deceive  you,  by  representing  the  simple 
methods  I  am  going  to  speak  of  as  infallible  ;  so  much  the  re- 
verse, that  though  they  seem  to  me  at  once  the  best  and  the  most 
simple,  though  I  have  always  entered  upon  this  part  of  the 
operation  with  confidence,  I  have  never  finished  without  a  de- 
gree of  diffidence  and  uncertainty. 

I  have  often  found,  especially  in  firm  and  smooth  polypi, 
that  I  have  by  that  quick  and  forcible  retraction  of  the  ligature, 
by  which  I  draw  it  up  behind  the  polypus,  hitched  it  at  once  so 
high,  that  no  after-operation  was  either  necessarv  or  useful. 


456  Of  large  and  guttural  Polypi. 

But  the  attempt  to  hitch  the  ligature  high,  and  place  it  correctly 
round  the  neck  of  the  tumour,  can  never  be  superfluous :  the 
instrument  I  most  frequently  use  is  a  boy's  catheter,  or  one  of 
the  smallest  size,  cut  across  about  the  middle,  or  somewhat 
short  of  the  middle  of  its  curve.  Taking  one  of  the  ends  of  the 
wire  as  it  hangs  out  of  the  nostril,  I  pass  it  through  the  tube  of 
the  catheter,  and  then  holding  both  ends  of  the  wire  or  noose 
firm,  I  pass  the  catheter  deep  into  the  nostril,  along  the  wire, 
till  I  imagine  the  point  of  the  catheter  touches  the  tumour  ; 
then,  by  tightening  both  ends  of  the  wire,  and  turning  the  point 
of  the  catheter  upwards,  I  try  to  raise  that  side  of  the  wire  or 
ligature  as  high  as  possible  ;  I  then  withdraw  the  catheter,  pass 
the  opposite  side  ot  the  wire  through  it  ;  I  hold  all  tight  again, 
and  try  to  raise  that  side  of  the  noose  as  high  as  possible  ;  I 
then  pass  both  wires  through  the  tube  of  the  catheter  at  once, 
push  the  catheter  along  till  it  touches  the  tumour,  pull  both  ends 
of  the  ligature  so  as  to  tighten  it  round  the  neck  or  smaller  part 
of  the  polypus,  and,  twisting  the  wire  fast  round  the  handle  of 
the  catheter,  I  leave  it  there.  More  frequently  I  use  for  this 
latter  purpose  a  shorter  tube,  or  very  small  section  of  a  cathe- 
ter, a  little  bended,  which,  when  fixed,  projects  no  more  than 
an  inch,  or  an  inch  and  a  half  beyond  the  nostril,  and  is  less 
apt  to  be  discomposed  by  accidents  during  the  day,  or  change 
of  posture  while  the  patient  lies  asleep.  Sometimes  I  have 
run  along  the  line  of  the  ligature  to  hitch  it  higher,  a  probe 
with  the  point  bent.  Sometimes,  giving  the  loop  a  twist  in  its 
middle,  I  have,  before  introducing  it  through  the  nostril  into 
the  throat,  tied  a  ligature  of  waxed  thread,  or  cat-gut,  to  the 
loop  of  the  wire,  the  twist  of  which  keeps  the  regulating  liga- 
ture in  the  centre,  so  as  to  raise  the  proper  ligature  and  adjust 
its  place.  When  a  loop  of  wire  is  thus  mounted  and  in- 
troduced into  the  nose,  and  the  loop  caught  in  the  throat,  and 
retracted  through  the  mouth,  this  assistant-ligature  is  fixed  on 
the  centre  of  it ;  the  noose  of  wire  is  then  carried  into  the  throat 
upon  the  conical  fingers  of  the  right  hand,  and  cast  over  the 
tumour,  and  retracted  behind  it,  as  I  have  already  explained, 
and  of  the  three  ends  hanging  out  of  the  nostril,  you  raise,  first 
this  supplementary  ligature,  by  running  the  catheter  along  it, 
and  thus  you  make  sure  of  hitching  the  centre  of  the  loop  oi 
silver  wire  higher,  after  which  you  carry  each  of  the  sides 
higher,  by  running  the  tube  along  them,  and  if  you  know  the 
windings  of  the  passages,  and  have  formed  a  true  conception 
of  the  form  of  the  polypus  you  have  to  deal  with,  your  chance 
is  tolerable  of  placing  the  ligature  very  true.  If  there  be  a  se- 
cond polypus,  one  in  the  nostril  as  well  as  one  in  the  throat, 
this  method  enables  you  to  carry  the  same   ligature  at  once 


Of  large  and  guttural  Polypi.  45T 

round  both.  I  have  occasionally  done  this  with  the  common- 
eyed  probe,  but  the  eyed-end  of  the  probe,  though  from  its  flat- 
ness it  glides  pretty  well  along  the  sides  of  the  tumour,  is  too 
big  to  turn  easily,  and  too  sharp  in  its  point  ;  but  a  surgeon  in 
the  country  may,  by  clipping  off  the  point  with  scissors,  and 
hammering  and  rounding  it  upon  a  stone,  fit  it  for  this  use.  I 
have  occasionally  used  lor  this  purpose  a  piece  of  suffer  wire 
twisted  into  a  loop,  for  conducting  the  ligature  down  into  the 
throat,  or  placing  it  correctly,  and  hitching  it  high  upon  the 
neck  of  the  polypus.  In  performing  this  operation  then  I  take 
only  a  catheter  nicely  cut  and  smoothed,  a  few  waxed  ligatures 
and  cat-guts  of  various  dimensions,  small  and  flexible  wire,  for 
forming  the  noose,  and  thicker  and  firmer  brass  wire  to  use  for 
this  purpose,  with  cutting  pliers,  and  common  pincers,  to  turn 
and  twist  the  wires  into  whatever  shapes  best  suit  the  occasion, 
or  the  accidents  of  the  case. 

Fifthly,  Of  the  effects  of  the  ligature  on  the  tumour,  and  of 
the  time  of  its  separation.  When  you  first  draw  the  noose,  the 
stricture  is  followed  with  extreme  pain,  the  eyes  fill  with  water, 
the  patient  cries  out  and  retracts  his  head,  and  violent  sneezing 
follows  ;  during  the  whole  of  the  first  and  second  day,  the  pain 
is  like  that  of  severe  tooth-ach,  and,  upon  tapping  with  the  fin- 
ger upon  the  catheter  or  probe,  you  find  it  firm.  On  the  third 
day,  a  thin  and  bloody  serum  begins  to  distil  from  the  noose, 
and  continues  to  flow  in  great  profusion,  the  probe  or  catheter  is 
blackened  by  the  putrid  taint  of  this  serum,  the  polypus  if  any 
part  of  it  project  so  as  to  be  felt,  is  perceived  to  be  flaccid,  the 
breath  begins  to  pass  through  the  nostril,  and  the  patient,  who 
had  felt  his  fauces  choaked  with  the  polypus,  and  was  deaf  from 
its  pressure,  now  swallows  easily,  and  hears  very  acutely,  because 
the  tumour  begins  to  shrink. 

These  are  the  first  auspicious  signs  of  the  fading  of  the  poly- 
pus :  the  fetor  of  the  matter  increases  on  the  fourth  and  fifth 
days,  the  probes  and  silver  wire  are  still  more  blackened,  the 
wire  manifestly  has  become  looser  from  the  shrinking  of  the  tu- 
mour, the  catheter  now  shakes  from  side  to  side,  and,  that  it 
may  completely  destroy  the  polypus,  you  find  it  necessary  to 
draw  it  a  little  closer  in  proportion  as  the  tumour  yields.  Not 
unfrequently  it  happens,  that  at  this  time  the  probe  or  catheter 
comes  easily  away  ;  but  if  the  ligature  continue  to  retain  its  hold, 
it  is  but  for  a  day,  or  at  the  utmost  two  days  longer;  and  though 
the  pain  is  not  renewed,  the  polypus,  being  now  less  sensible, 
the  parts  are  still  more  blackened,  the  discharge  is  extremely 
fetid,  thin,  and  copious ;  some  blood  usually  flows  at  this  time, 
the  swallowing  improves,  and  the  hearing  grows  too  acute,  ir- 
regular, and  confused  ;  the  tube  falls  away  on  the  sixth,  seventh, 

3  M 


45k.  Of  large  crnci  guttural  Polypi. 

or  eighth  day,  and  often  it  happens,  that  the  tumour  melts  awajr 
so  entirely,  and  is  resolved  into  this  gangrenous  ichor,  that  no 
perceptible  portion  of  it  tails  away  :  sometimes,  continuing 
more  entire,  it  drops  into  the  throat,  and  the  patient  n  jects  it ; 
often  when  it  drops  into  the  oesophagus  it  is  swallowed,  and  is 
passed  undigested  by  stool ;  sometimes  the  patient  is  conscious 
of  having  swallowed  the  tumour,  but  more  usually  it  pusses  over 
the  throat  insensibly,  and  during  sleep.  I  have  known  it  hap- 
pen, especially  in  the  hands  ol  ignorant  people,  that,  after  the 
poly  pus  has  dropped  off,  and  actually  been  passed  by  stool,  the 
tube  and  wire  have  kept  their  place,  without  the  reason  being  at 
all  suspected  :  it  is  this,  that  the  loop  of  the  ligature  is  larger 
than  that  narrow  slit  of  the  nostril,  through  which  it  should  pass, 
and  thus  it  hangs  suspended,  and  I  have  known  it  hang  so  a 
month,  but  loose,  moveable,  and  easily  taken  away.  I  do  not 
know  that  the  loop  of  wire  ever  needs  be  left,  even  in  the 
most  bulky  and  cartilaginous  polypus,  beyond  the  eighth  day. 

These  are,  I  believe,  the  most  material  rules  and  directions 
I  have  to  give  you ;  but  there  are  some  oi  them,  perhaps,  that 
I  ought  to  explain  or  to  impress.  The  operation  which  use 
has  made  easy,  or  frequent  success  has  inclined  us  to  prefer  to 
all  others,  we  are  apt  to  praise  too  much ;  but  I  am  conscious, 
that  it  is  a  serious  duty  to  represent  this  not  favourably,  but  tru« 
ly.  The  operation  of  noosing  a  poly  pus,  is  not  suited,  in  any 
degree,  to  these  small  and  soft  polypi,  which  occupy  only  the 
nose,  bi>:  to  those  big  and  solid  ont  s,  which  depress  the  palate, 
and  are  felt  in  the  throat.  It  is  most  natural  for  the  young  sur- 
geon to  believe  a  polypus  the  more  formidable,  the  greater  its 
size ;  but  indeed  it  is  impossible  to  grapple  with  those  which 
are  not  large  ;  those  are  most  easily  grappled  with  the  points  of 
the  fingers,  and  noosed  with  the  loop  or  ligature,  which  are  very 
conspicuously  large. 

Some  apparatus  you  will  assuredly  require  ;  you  would  irrla  • 
gine  many  and  curious  instruments  necessary ;  you  must  have 
small  catheters,  or  other  tubes,  you  must  have  a  blunt  hook  for 
hooking  the  noose  forwards,  as  soon  as  it  appears  in  the  throat, 
a  pair  of  common  dressing  forceps,  which  indeed  I  find  best, 
silver  wire  of  various  thickness,  and  pliers  for  twisting,  and  cut- 
ting forceps,  or  strong  scissors,  lor  dividing  it;  but  having  had 
much  experience  in  such  operations,  and  seen  even  varictv  of 
the  disease,  I  protest  I  know  of  no  circumstances  in  which  I 
would  not  prefer  a  bit  of  silver  wire  mamiged  with  my  fingers, 
and  passed  down  into  the  throat,  without  a  tube,  drawn  out 
with  dressing  forceps  from  the  throat,  formed  into  a  loop,  and 
thrust  over  the  tumour  with  my  three  first  fingers  of  the  right 


Of  large  end  guttural  Polypi..  45S 

hand,  in  a  conical  form,  to  the  most  ingenious  instruments  that 
ever  were'devised. 

An  operation  so  effectual  and  radical,  and  yet  so  little  alarm- 
ing, i  do  nut  know  ;  lor  the  surgeon  presents  himself  without 
instruments,  with  only  a  bit  of  silver  wire  in  his  hand,  and  with 
the  professed  intention  too,  not  of  cutting,  tearing  or  cauteriz- 
ing, but  merely  ol  casting  a  noose  round  the  tumour,  as  round 
a  wart  on  the  surface  ol  the  skin.  Nor  are  the  efforts  made 
ia  applying  that  noose,  though  violent,  at  all  dangerous;  they 
are  not  fatal,  like  those  ol  an  unskilful  surgeon  gi'oping  in  the 
lacerated  bladder  lor  a  stone;  there  is  hi  re  no  incision,  and 
the  surgeon  is  grappling  for  a  hold  of  an  uninflamed  tumour, 
in  natural  passages,  which,  though  they  be  inflamed  by  his  un- 
skilfulncss  or  rudeness,  (and  1  have  seen  them  inflamed  se>  that 
the  whole  throat  has  swelled  exceedingly)  jet  such  inflamma- 
tion does  no  material  harm. 

But,  though  harmless,  the  efforts  necessary  for  noosing  the 
polj  pus  makes  it  a  moment  <A  great  agitation  and  anxiety  for 
the  surg  on  :  his  patient  strains,  and  suffocates,  during  his  at- 
tempt; however  long  it  lasts,  breathing  is  suspended  ;  the  eyes 
are  filled  with  water,  the  blood  gushes  from  the  mouth  and 
nostrils,  the  fingers,  or  rather  the  hand  ol  the  operator,  is  dri- 
ven deep  into  the  throat ;  and  the  patient  is  held  staring,  and 
struggling,  at  once  terrified  by  a  sense  of  suffocation,  excited  to 
vomit,  and  alarmed  and  pained  bv  the  pushing  of  the  op<  rator, 
who  is  obliged  to  push  his  finger  deep,  before  he  even  feels  the 
tumour,  behind  the  palate,  who  grapples  hard  before  he  gets  the 
lower  part  of  it  within  the  grasp  of  the  fingers,  and  pushes  still 
more  violently,  and  struggles  much,  before  he  can  pass  the  loop 
of  the  wire  beyond  and  over  it  :  it  is  a  painful,  and  to  the  spec- 
tators an  apparently  desperate  and  unavailing  struggle  ;  it  is  dif- 
ficult to  perform  in  the  living  subject,  tor  in  one  moment  ot  vi- 
olent struggling  a  thing  is  to  be  accomplished,  which  j  ou  have 
no  opportunity  of  trying  previously  in  the  dead  body  :  it  is  also 
to  be  accomplished  at  once,  for  if  the  operator  suffers  himself  to 
be  once  foiled,  he  may  be  so  fifty  times,  and  never  succeed  : 
never,  therefore,  attempt  this  operation  in  the  presence  of  stu- 
dents, nor  think  of  it  as  an  exhibition  of  skill,  but  privately, 
with  one  or  two  chosen  friends,  when  having  no  concern  about 
your  own  reputation,  or  shame  or  fear  of  being  foiled,  your 
whole  thoughts  are  occupied  with  your  patient. 

Like  the  operations  of  midwifery,  such  as  turning  the  child, 
or  dilating  the  womb  in  floodings,  this  requires  a  degree  ot 
strength,  and  a  sort  of  cruel  violence,  which  the  inexperienced 
surgeon  cannot  allow  himself  to  use  ;  insomuch,  that  one  who 
has  often  performed  it,  forgets  that  there  is  any  skill  required, 


46.0  Of  large  and  guttural  Polypi. 

and  knows  not  how  to  describe  the  art  he  does  use.  So  great 
is  the  force,  that  I  long  imagined  that  nothing  but  courage  was 
necessary  ;  I  was  not  aware,  that  in  a  matter  so  simple,  there 
was  occasion  for  particular  address  ;  and  among  many,  whom 
I  have  seen  try  in  vain  to  noose  a  polypus,  I  represented  to  one 
gentleman,  that  he  had  but  to  push  his  fingers  more  courage- 
ously into  the  throat,  and  he  could  not  fail  to  distinguish  the 
polypus,  and  alter  a  short  struggle  to  noose  it ;  this  was  the 
only  point  of  my  instructions  in  which  he  did  not  fail.  More 
desperate  struggles,  I  confess,  I  never  witnessed ;  and  when, 
after  twenty  attempts,  I  perceived  that  it  was  impossible  he 
should  succeed,  I  found  it  as  difficult  to  disengage  him  from 
the  patient  as  a  mastiff  from  his  hold,  he  seemed  furiously  re- 
solved not  to  be  defeated  in  what  was  esteemed  easy,  and  ne- 
cessary for  the  patient,  nor  disgraced  before  a  whole  theatre  of 
students. 

The  surgeon  must,  in  performing  this  part  of  his  operation, 
be  prepared  to  use  great  force  ;  he  first  draws  out  the  loop  from 
the  throat,  then  spreads  it,  then  passes  the  three  first  fingers  of 
his  right  hand  in  a  conical  form  into  the  loop,  then  retracts  the 
wire  in  the  nostrils  with  the  left  hand,  so  as  to  straiten  the 
loop  upon  the  fingers  of  the  right  hand,  that  it  may  not  shift, 
then  pulling  back  the  wire  with  the  left  hand,  he  gradually  in- 
troduces the  right  hand  into  the  mouth,  conducting  the  loop 
upon  the  points  of  his  fingers.  He  next  prepares  for  the  final 
exertion,  by  pulling  the  ligature  smartly  with  the  left  hand, 
thrusting  the  right  hand  forwards  into  the  throat,  distending  the 
mouth  more  and  more,  and  pushing  the  hand  deeper,  till  he  not 
only  feels  the  tumour,  but  passes  beyond  it  with  the  points  of  his 
fingers,  hooks  it  towards  him  with  the  crooked  finger-points,  as 
in  the  motion  of  tickling,  pushing  the  ligatures  up  with  the 
backs  of  the  fingers  at  the  same  moment,  and  pulling  it  very 
strongly  back  into  the  nose ;  the  throat  all  the  while  re-acts  and 
assists  him.  This,  as  far  as  I  am  conscious,  is  the  manner  in 
which  I  have  successfully  noosed  the  polypus,  and  in  no  in- 
stance have  I  yet  failed  wherever  I  conceived  it  to  be  of  suffi- 
cient size  for  such  an  operation.* 

*  It  is  eafy  to  imagine  the  manner,  and  ftill  eafier  to  underftand  the  effecT:  of 
thefe  manoeuvres,  but  to  execute  them  is  extremely  difficult,  as  I  am  now  per- 
fuaded ;  for  1  have  feen  furgeons,  by  no  means  awkward  or  ignorant,  mifcarry 
moil  inexplicably  in  this  fimple  operation  of  applying  the  noofe. 


Of  large  and  guttural  Polypi.  461 


HISTORY    OF    THE    DISEASE. 

"  The  case  of  A.  Gow  is  one,  I  believe,  particularly  suited 
to  convey  clear  impressions  of  this  second  stage  of  the  disease, 
in  which  the  tumour  is  bulky,  fit  for  the  application  of  the  noose, 
and  not  yet  accompanied  with  any  caries  of  the  bones.  'J>o\v 
is  a  hard-working  young  man  of  twenty-one  years  of  age,  ap- 
prentice to  a  mill-wrightin  Blair  Athol ;  his  polypus  is  big,  and 
of  a  stony  hardness  ;  it  choakes  the  fauces,  as  if  a  fist  with  its 
knuckles  downwards  were  thrust  into  the  throat ;  the  chief  bulk 
of  the  tumour  descending  from  the  back  of  the  nostrils,  pushes 
out  the  soft  palate  into  a  great  convexity,  so  that  it  presses  the 
root  of  the  tongue  ;  two  large  knuckle-like  tubercles  of  the  po- 
lypus project  below  the  curtain  or  moveable  palate,  and  on  the 
centre  of  the  convexity  formed  by  the  protruded  soft  palate, 
are  two  long  gashes  of  incision,  made  apparently  with  the  ex- 
pectation of  letting  out  matter  by  his  country  surgeon,  and  now 
in  suppuration.  There  is  no  part  of  the  polypus  projecting  from 
the  nostril,  the  bulk  of  the  tumour  is  in  the  fauces,  yet  the  lace 
is  deformed,  the  nose  being  inclined  to  one  side,  as  if  a  branch 
of  the  polypus  were  lodged  there.  There  have  been  frequent 
and  very  profuse  hemorrhages  ;  the  parts  within  the  nose  are 
greatly  endangered  by  the  pressure,  which  is  attended  with 
considerable  pain ;  but  as  yet,  no  matter  distils  from  the  nos- 
trils or  throat,  there  have  been  no  intense  pains  in  the  cheek, 
the  maxillary  and  nasal  bones  seem  firm  and  sound,  the  disease 
is  advanced  to  the  farthest  verge  of  the  second  stage,  and  be- 
ginning of  the  third,  in  which  the  bones  and  Schneiderian  mem- 
brane fall  into  incurable  ulceration  :  nothing  has  saved  the  pa- 
tient from  such  caries,  but  that  the  tumour,  though  very  bulky, 
is  but  of  recent  growth  ;  it  is  of  such  a  size  as  to  be  extremely 
favourable  for  operation,  before  applying  the  noose,  I  take  the 
following  notes  of  its  progress. 

"  The  lower  order  of  people  are  coarse  and  hardy,  verv 
little  attentive  to  their  health  ;  it  is  not  a  slight  alteration  of  the 
voice,  slight  obstruction  of  the  nose,  or  occasional  haemorrhage?, 
that  can  alarm  them  ;  thence  it  happens,  that  the  date  they 
assign  for  such  a  tumour,  is  not  the  beginning  of  its  growth, 
but  that  stage  of  its  progress  in  which  it  occasions  particular 
distress.  It  is  no  more  than  six  months  since  Gow  suspected 
any  thing  to  be  wrong  in  his  throat  or  nostril  ;  he  had  tooth- 
nch,  and  had  a  tooth  pulled,  without  any  possible  relation  to 
his  present  ailment,  the  first  sensible  sign  of  which  wns  ha.>morr- 
hagy  from  the  nose  :  during  eight  or  ten  days,  he  seldom  rose 
jn  the  morning^viihout  violent  hxmorrhagy,  which  sometimes 


462  Of  large  and  guttural  Polypi. 

recnrred  during  the  day,  or  in  the  evening,  but  it  ceased  spon- 
taneously. 

"  About  a  month  after  this  first  attack,  the  occasional  haemorr- 
hagy  returned  in  all  its  violence  ;  he  bled  prolusclv  irom  the 
nose,  not  only  in  the  morning,  but  at  all  hours  of  the  day  and 
night  ;  all  the  usual  methods  of  restraining  it  now  failed,  he  fell 
into  extreme  weakness  ;  and,  to  use  his  own  homely  expression, 
"  seemed  to  have  bled  out  all  the  blood  of  his  body." 

"  One  day  when  he  was  out  in  the  duke's  woods,  with  his 
master,  the  mill-wright,  cutting  wood  for  their  work,  he  ob- 
served, in  blowing  his  nose,  that  he  could  not  blow  with  his 
right  nostril  ;  he  felt,  at  the  same  time,  something  uneasy  in 
his  throat,  and  directed  by  this  feeling,  pushed  his  finger  as  far 
back  as  it  could  go,  and  then  he  plainly  felt  a  soft  lump,  obstruct- 
ing his  throat,  and  hindering  his  free  breathing  ;  and  being 
greatly  alarmed,  he  begged  his  master  to  look  into  his  throat, 
who  saw  the  lump  very  plainly.  Thus  vou  perceive  in  this 
coarse  country  lad,  little  in  the  habit  of  observing  his  own  feel- 
ings, and  not  easily  discomposed  by  trifling  uneasiness  or  dis- 
eases, which  in  a  more  delicate  person,  and  in  a  higher  rank  in 
life,  would  have  caused  great  alarm.  The  polypus  was  not  ob- 
served, till  after  it  had  occasioned  very  profuse  haemorrhages, 
and  had  grown  to  a  very  remarkable  size. 

"  The  tumour  increased  rapidly  ;  it  was  the  difficulty  of 
breathing,  and  uneasy  feeling  in  the  throat,  that  first  led  him  to 
the  discovery  ;  and  being  sensible  that  the  lump  in  his  throat 
was  still  growing,  and  feeling  his  right  nostril  particularly  stuff- 
ed, he  introduced  his  finger  there,  from  time  to  time,  and  was 
sensible  also  of  a  smaller  lump  obstructing  his  nose. 

tv  At  this  period  when  he  had  difficulty  of  breathing,  with  a 
total  obstruction  of  the  right  nostril,  difficulty  of  swallowing, 
with  a  d<  gree  of  deafness  in  the  right  ear,  he  had  no  distinct 
tooth-ach,  but  a  general  uneasiness,  sense  of  pressure,  and  con- 
fused pain  in  the  head :  but  he  had  no  returns  of  the  haemorr- 
hage, and  only  a  thick,  white,  and  starch-like  mucus,  a  mere 
increase  of  the  natural  secretion  distilled  from  the  nose. 

u  In  this  stage  of  the  disease  it  was,  that  he  first  applied  to  a 
surgeon,  a  vers  ignorant  one,  who  performed  a  singular  opera- 
tion ;  the  incisions  which  he  made  are  still  in  a  state  of  suppu- 
ration. The  lad  went  to  this  surgeon  to  complain  of  difficulty 
of  breathing,  and  a  lump  growing  in  the  throat,  which  he  could 
easily  see  and  feel.  The  surgeon  having  heard  of  swellings 
of  the  tonsils,  and  obstructions  of  the  throat,  and  read  perhaps 
of  the  operation  of  scarifying  the  tonsils,  to  let  out  the  matter, 
knowing  nothing  of  diseases,  and  apprehending  that  the  tumour 
he  saw  could  be  nothing  but  the  swelled  tonsils,  he  proceeded  to 


Of  large  and  guttural  Polypi.  463 

make  two  long  and  deep  incisions.  This  bulky  and  firm  poly- 
pus, having  pushed  down  the  velum,  had  depressed  it  to  a  right 
angle  with  the  bony  palate:  and  the  sottvtlum,  with  its  uvula,  was 
thus  protruded  forwards  in  the  mouth,  in  the  form  of  a  tumour, 
so  far,  that  you  could  easily  touch  it  with  the  finger.  He  per- 
haps imagined  it  some  great  abscess  of  the  tonsil  :  he  made,  with 
what  instrument  I  know  not,  two  long  incisions,  each  more 
than  an  inch  long,  parallel  with  each  other,  down  through  the 
very  centre  of  the  velum,  and  the  same  pressure  which  thus 
extended  the  velum  continuing  and  increasing,  has  so  dilated 
the  two  incisions,  as  to  prevent  them  healing  :  they  are  to  ihi& 
day  in  a  state  of  suppuration,  with  red  and  hardened  edges, 
though  it  is  full  two  months  since  they  were  made. 

u  The  surgeon  said  he  would  come  back  and  complete  this 
operation  ;  what  he  designed  next  to  do  it  is  difficult  to  conjec- 
ture ;  but  fortunately  for  Alexander  Gow,  the  operator,  while 
meditating  upon  the  operation,  died,  probably  from  solacing 
himself  after  hard  rides  with  too  strong  a  cup;  and  soon  after 
his  death,  Gow  came  to  town  to  have  some  operation  per- 
formed." 

NOTES  OF  THE  OPINION  IN  THIS  CASE  OF    GOW. 

"  The  tumour  is  big,  distinctly  felt  behind  the  velum  pendu- 
lum, easily  grappled  with  and  noosed  :  the  stage  of  the  disease 
is  urgent,  the  pain,  deafness,  stupor,  and  affection  of  the 
voice,  shew  the  pressure  to  be  such  that  we  cannot  for  one  mo- 
ment reckon  upon  the  part  continuing  sound,  the  operation 
should  be  immediately  performed." 

The  annexed  figure  is  a  true  drawing  of  this  polypus  which  I 
found  of  this  size,  exceedingly  hard  and  cartilaginous,  and  so  firm, 
that  a  delicate  knife  might  be  broken  on  it,  before  it  could  be  di- 
vided. Such  is  the  tumour,  which  would  in  former  times  have 
been  cut  out,  or  torn  imperfectly  away,  after  cleaving  the  palate 
not  partially,  as  was  done  by  the  Dunkeld  surgeon,  but  entirely. 
I  extirpated  this  polypus  with  a  noose  of  silver  wire,  after  the 
usual  severe  struggle  in  passing  and  adjusting  the  noose  ; 
whether  the  point  (a  )  be  that  small  projection  which  was  felt 
deep  within  the  nostril,  I  do  not  know;  but  the  broad  surface 
(7>J,  which  either  implied  that  this  polypus  had  not  a  narrow 
pedicle,  or  that  the  ligature  had  not  been  fortunately  placed, 
alarmed  me.  I  was  long  without  tidings  of  this  young  man, 
and  feared  lest  he  had  been  cut  off  by  a  return  of  the  disease  ; 
but  just  now,  at  the  distance  of  eight  years  from  this  operation, 
I  have  recognised  him  a  waiter  in  a  tavern,  and  in  strong  health, 
and  grown  a  stout  and  athletic  man. 


464  Of  large  and  guttural  Polypi, 


In  another  case  of  a  boy  of  fourteen  years  of  age  I  applied  the 
ligature  with  the  usual  painful  struggle,  but  he  bore  it  well  :  the 
tube  for  tightening  the  ligature  stood  very  firm  :  he  was,  on  the 
4th  day,  relieved  of  the  tube  and  ligature,  which  dropt  away  ; 
and  at  the  same  time,  of  his  deafness  and  stupor,  recovering 
with  all  his  natural  voice.     But,  though  I  have  noosed  many 
polypi  successfully,  in   this   I  certainly  failed  ;  I  imagined  I 
had  noosed  both  polypi  effectually,  for  both  dropt  away,  and  he 
was  conscious  one  night  of  swallowing  that  one  which  choaked 
the  fauces  ;  but  either  the  polypus  projecting  forwards  into  the 
nostril,  had  in  part  escaped  ;  or,  from  the   ligature  embracing 
both,  they   had  been   imperfectly   compressed  :  or  there  had 
lurked  behind  them  a  third  polypus,  which  indeed  I  conceive  to 
be  the  most  likely  conjecture  ;  hut  the  disease  actually  returned, 
in  a  few  months  he  came    back  to  me  with  a  voice  as  much 
affected,  and  the  guttural  part  of  the  polypus  as  bulky  as  at  first. 
Though  mortified,  I  was  not  discouraged  by  my  ill  success,  but 
addressed  myself  again  to  the  business,  and  noosed  this  new 
tumour,  taking  every  precaution  to  carry  the  ligature  quite  up 
to  the  root,  and  I  am  confident  this  boy  was,  by  this  second 
operation,  perfectly  cured,  I  saw  him  grow  a  fine  stout  young 
man,  and  I  must  have  been  his  sole  resource  had  the  disease 
returned  a  third  time,  for  the  operation  was  bloodless,  not  at  all 
alarming,  and  little  painful,  and  his  relief  perfect.     When  I 
operated  on  this  polypus  I  supposed  there  was  but  one  root  to 
both  tumours,  but  I  have  since  changed  my  opinion  on  this  sub- 


Of  large  and  guttural  Polypi.  465 

ject,  and  am  persuaded  that,  wherever  there  are  two  or  more 
polypi,  they  are  distinct  in  their  roots,  as  in  their  bodies.  This 
was  just  Gow's  polypus  in  embryo,  and  I  speak  of  it  to  you  as 
an  example  of  two  polypi  ;  and  a  warning  of  the  unlooked-for 
disappointments  you  will  have  to  brook,  if  you  are  engaged  in 
this  line  of  practice. 


SECTION  III. 

Of  the  third  and  last  stage  of  Polypus. 

The  last  and  fatal  stage  of  this  disorder  you  will  know  even 
at  sight  by  strong  and  characteristic  marks  ;  by  the  humid  half- 
closed  eye,  moving  slowly  and  half  drowned  in  water  ;  by  the 
snuffling  voice,  the  total  deafness,  the  stupor  and  languor,  ap- 
proaching to  apoplectic,  the  distorted  nose,  and  pallid  trans 
parent  wax-like  face  ;  while  the  loose  nasal  bones,  and  puffy 
cheek,  denote  the  incurable  stage  of  the  disease  ;  the  puffy  inte- 
guments and  softened  bones,  and  fetid  matter  running  from  the 
nose,  prove  that  all  you  have  in  your  power  to  do  by  an  ope- 
ration is  to  save  the  patient  for  a  little  while  from  dying  of  has- 
morrhagy. 

"  When  first  I  visited  Mr.  Cameron,  his  whole  form  and 
countenance  and  state  of  suffering  struck  me :  he  was  a  fine 
young  man,  about  25  years  of  age,  tall,  athletic,  and  had  been 
noted  for  his  strength  in  all  kinds  of  exercise  and  feats  of 
strength.  His  form  was  emaciated,  his  face  deadly  pale,  with 
a  ghastly  transparency  of  skin,  which  gave  his  countenance  the 
appearance  of  modelled  wax,  this  proceeded  from  the  frequent 
loss  of  blood.  There  was  a  remarkable  torpor  and  heaviness 
in  the  eyes,  which  were  half  closed  ;  for  hyemorrhagy  brings 
on  a  languor  and  sleepiness  which,  in  a  case  like  this,  is  in- 
creased by  an  actual  disorder  of  the  brain.  His  nose  was  in- 
clined much  to  one  side,  and  his  face  greatly  deformed,  not 
merely  by  the  rising  of  the  cheek-bone,  and  the  dilatation  of  the 
nostril,  but  from  the  swelling  of  the  whole  of  the  right  side  of 
the  head,  which  seemed  universally  enlarged.  The  right  eye 
was  turned  obliquely  in  its  socket,  and  almost  closed  ;  a  large 
and  massive  branch  of  polypus  projected  from  the  right  nostril ; 
and  looking  into  the  throat,  I  saw  the  soft  palate  pressed  for- 
wards by  a  second  polypus  as  big  as  the  fist ;  from  continual 
pain  of  the  caries,  the  tears  streamed  unceasingly  down  his 
cheek,  so  that  he  saw  confusedly  ;  the  saliva  flowed  continually 
from  his  mouth,  and  involuntarily,  while  a  foul,  black,  and  cor- 
roding  sanies,  distilled  from  the  nostril,  and  excoriated  and 

3  N 


466  Of  large  and  guttural  Polypi. 

swelled  die  upper  lip.  He  said  his  head  was  continually  tor- 
tured, as  if  squeezed  from  temple  to  temple  in  an  iron  vice. — 
He  sat  pale  as  a  spectre,  hanging  over  the  fire,  though  in  the 
hottest  season  of  the  year,  his  knees  almost  touching  the  grate, 
resting  his  head  upon  his  hand,  and  waving  it  to  and  fro  with 
continual  agony,  moaning  and  complaining.  His  visage  was 
pale,  his  lips  bloodless,  and  every  thing  about  him  demoted 
despair,  and  the  most  perfect  indifference  about  life..*j  He 
was  so  deaf  as  to  be  nearly  iusensible  to  noise  ;  you  could 
scarcely  make  him  understand  you,  even  when  you  halloed 
in  his  ear  ;  he  was  unconscious  when  any  one  entered  the 
room,  or  shut  the  door ;  his  teeth  were  loose  on  the  affected 
side,  and  some  had  dropped  from  their  sockets  ;  he  was  able  to 
swallow  liquids  only,  and,  partly  from  this  cause,  but  rather 
from  despair,  he  refused  all  sustenance,  drank  only  water  to 
slake  his  thirst,  and  to  every  kind  or  encouraging  expression 
he  always  replied,  "He  knew  he  could  not  be  cured,  he  wished 
he  could  die." 

"  At  the  distance  of  two  years  from  the  commencement  of 
his  complaint,  this  poor  man  requested  my  assistance  in  circum- 
stances altogether  desperate,  when  little  could  be  done,  even  to 
prolong  life,  where  to  save  it  nothing  but  a  miracle  could  avail. 
I  was  induced  by  his  earnest  and  imploring  manner  to. do  what- 
ever was  in  my  power,  and,  encouraged  by  this  reflection,  that, 
in  such  desperate  circumstances,  every  partial  success,  though 
it  seems  simply  to  prolong  life,  is  followed  by  an  interval  of 
tranquillity  and  hope ;  and  by  this  rule  and  feeling  I  shall 
always  be  guided,  doing  as  I  would  be  done  by,  persevering 
always  even  after  all  hope  is  over,  if  conscious  that  I  am  doing 
no  direct  injury.  I  have  told  you  how  he  was  exhausted  by 
suffering,  how  distracted  with  pain,  how  overcome  with  stupor, 
except  in  the  moment  of  violent  suffering,  and  when  I  tell  you 
that,  upon  the  slightest  intimation,  'that  the  prospect  of  saving 
him  was  very  small  by  an  operation,  he  refused  food,  I  repre- 
sent in  one  word  his  despair.  The  haemorrhage  was  particu- 
larly terrifying  ;  and  he  obtained  a  promise  of  me,  that,  upon 
the  first  return  of  it,  I  should  introduce  the  plugs  to  arrest  it : 
from  this  moment  I  was  entirely  embarked  in  a  desperate 
cause;  when  the  hsemorrhagy  returned,  which  it  did  with 
violence,  and  at  midnight,  I  passed  a  ligature  and  drew  up 
plugs  from  the  throat  to  the  back  of  the  nostril,  and  thus  pre- 
vented him  actually  expiring,  for  he  was  now  too  far  exhausted 
to  bear  loss  of  blood. 

"  I  now  called  a  full  consultation,  and  was  not  merely  per- 
mitted but  advised,  at  his  request,  to  try  every  method  :  1  pro- 
ceeded by  passing  a  wire  through  the  nostril,  and  drawing  it 


Of  large  and  guttural  Polypi.  467 

from  the  throat  into  the  mouth,  to  noose  the  main  tumour, 
which  was  bulky,  depressed  the  palate  to  right  angles,  was  very 
visible  in  the  throat,  and  felt,  while  I  grappled  with  it,  as  bulky 
as  the  fist.  The  tube  which  I  used  tor  tightening  this  noose, 
stood  out  from  his  nostril  very  stiff,  having  a  very  firm  hold :  I 
had  also  been  careful  to  include  a  polypus  which  hung  down  in 
the  nostril,  and  thence  expected  after  the  operation  of  the  liga- 
ture, that  the  passages  should  be  tolerably  clear.  The  tube 
continued  rigid  and  very  firm  for  live  days;  he  had  in  the  very 
moment  of  tightening  the  wire,  and  for  several  days,  a  poignant 
excruciating  pain,  in  all  that  side  ol  the  head,  but  especially  in 
the  teeth  and  ear;  the  matter  flowed,  blacker,  and  more  fetid, 
discolouring  the  wire  and  the  tube.  On  the  fourth  day  the 
wire  slackened,  and  the  tube  could  be  moved  a  little  from  side 
to  side,  I  therefore  drew  the  wire  tighter:  on  the  fifth  he  was 
suddenly  restored  to  his  hearing,  he  was  sensible  oi  swallowing 
the  tumour,  the  wire  dropped  off,  his  pains  vanished,  he  swal- 
lowed easilv,  and  he  was  so  elated  with  hope  and  confidence, 
that  he  ate  heartily,  drank  his  wine,  look  exercise  abroad,  and 
felt  assured  of  what  no  prudent  man  could  promise,  an  abso- 
lute cure. 

"  This  was  the  period,  in  which  having  made  way  into  the 
nostrils  so  as  to  operate  freely,  I  should  have  searched  boldly 
with  my  finger,  introduced  mv  knives,  forceps,  and  caustics, 
and  resolutely  extirpated  the  brandies,  and  roots  of  the  polypi ; 
il  I  was  guilty  of  any  dereliction  of  duty,  it  was  from  no  sel- 
fish nor  trivial  motive  ;  this  was  a  case  so  desperate  in  all  res- 
pects, with  a  stupor  so  manifestly  implying  an  affection  of  the 
brain,  that  I  was  afraid  of  causing  inflammation  and  sudden 
death  ;  if  at  my  next  operation  I  was  more  resolute,  it  was  from 
despair,  joined  to  the  earnest  entreaties  iff  the  patient.  In  less 
than  a  fortnight  I  felt  the  tumour  from  the  nose  rising  again  ; 
at  this  time,  restored  to  strength,  and  spirits,  and  the  nostril 
open,  he  could  blow  through  it  so  freely,  as  to  dash  out  the  foul 
matter  and  blood  with  great  force,  and  my  fingers  could  pass 
deep  into  it.  There  was  no  sensible  tumour  in  die  throat,  but 
in  a  little  while  the  nostril  v  obstructed  ;   in  a  little  lon- 

ger, the  tumour  could  be  felt  a',     in   the  throat;  iorr- 

hages  returned,  so  that  he  was  in  dang  rofsuddtn  death — 
His  entreaties  were  renewed,  and  D  lessrs.  Wood, 

and  Harkness,  and  the  other  Gentlemen,  met  ag&'m  in  consul- 
tation, added  to  the  patient's  wish  of  having  these  attempts  re- 
newed, and  were  assembled  again  the  d  to  assist 
in  the  operation,  but  I  could  not  noose  the  polypus  as  at  first, 
not  because  of  its  lesser  size,  but  because  when  I  grappled  with 
the  tumour  in  the  throat,  it  recoiled  into   the  no  tril  ,  when  I 


468  <Jf  large  and  guttural  Polypi. 

resisted  this  by  plunging  a  finger  deep  into  the  dilated  nostril, 
and  met  and  resisted  the  tumour  there,  it  seemed  to  recede  in- 
to the  antrum  Highmorianum,  and  when  I  pursued  the  now 
moveable  tumour,  with  the  finger  among  the  cells,  I  found, 
to  my  inexpressible  horror,  that  every  bone  and  bony  cavity 
was  entirely  carious :  the  partition  which  divides  the  antrum 
from  the  cavity  of  the  nose  was  quite  destroyed :  the  polypus 
occupied  the  cavity  of  the  antrum :  the  edge  of  the  vomer 
rough,  carious,  and  disengaged  from  its  cartilage,  met  the 
finger,  and  the  nasal  branch  of  the  upper  maxillary  bone  was 
rotten :  the  polypi  felt  soft  and  mucous,  and  the  whole  seemed 
to  be  one  mass  of  corruption. 

"  Since  our  operation  was  begun,  though  it  could,  in  these 
circumstances,  be  nothing  but  unavailing,  still  the  patient's  en- 
treaties, together  with  our  natural  desire  to  give  him  every 
chance  of  life  prevailed.  To  prepare  for  this  severe  operation 
I  passed  a  ligature  by  the  nostril  to  the  mouth,  fixed  a  plug  of 
lint  to  it,  kept  it  ready  to  be  drawn  up  into  the  back  nostril,  in 
case  of  hsemorrhagy,  which  our  patient  could  ill  bear,  introdu- 
ced then  the  forceps,  and  catched  at  whatever  branches  of  po- 
lypus were  within  my  reach  ;  turned  the  instruments  in  every 
direction,  and  cleared  the  nostril  by  every  means,  however 
rude,  and  indeed  so  cleared  it  that  he  could  blow  freely,  and 
dash  out  a  clot  of  blood,  mixed  with  fragments  of  mangled  po- 
lypus, to  a  great  distance,  and  without  permitting  him  to  lose 
even  one  ounce  of  blood,  which  indeed  he  could  not  have  en-£ 
dured  ;  I  drew  up  the  plug,  and  made  all  .close.  In  three  days 
the  plugs  were  removed,*  the  nostril  was  in  full  suppuration, 
and  the  passages  seemingly  clear. 

"  But  the  same,  or  another  polypus,  soon  appeared,  small 
in  the  nostril,  more  considerable  in  the  throat ;  the  deafness, 
the  pains,  the  loss  of  voice,  and  the  difficulty  of  breathing  soon 
returned ;  and  the  patient,  who,  during  a  short  respite,  in  which 
he  had  eat,  and  drank  cheerfully,  and  recruited  his  strength, 
fell  again  into  a  state  of  despair  ;  and  above  all,  this  fear  was 
most  distracting  to  him,  that  we  should  sooner  or  later  abandon 
him  to  his  fate.  The  polypus  had  now  attained  such  a  size, 
that  it  was  again  possible*  to  noose  it ;  and  the  haemorrhages 
were   such  that  he  felt  distinctly  that  if  nothing  was   done  for 

*  In  removing  the  plug,  you  firfl  undo  the  knot  that  fecures  the  anterior  plug 
in  the  noflril ;  you  then  flacken  the  firing,  that  the  poflerior  plug  may  fall  down 
towards  the  throat ;  if  it  do  not  fall  down  fponcaneoufly,  you  pufh  againft  it  by 
paffing  a  probe  through  the  noflril,  holding  the  firing  at  the  fame  time,  that  the 
plug  may  not  go  quite  into  the  (Fauces:  you  put  in  your  drefiing  forceps,  catch  it 
at  the  back  of  the  palate,  pull  it  forwards  from  behind  the  velum,  and  having 
brought  it  out  of  the  mouth,  you  cut  the  firing  in  the  r.oftr:!,  you  thus  ex- 
tract it. 


Of  large  and  guttural  Polypi.  469 

him,  he  had  not  many  days  to  live.  The  ligature  was  again 
passed,  and  the  noose  cast  over  the  tumour,  and  in  four  or  five 
clays,  when  its  operation  was  complete,  the  nostril  was  so  clean 
and  at  the  same  time  so  dilated,  that  I  passed  the  finger,  and 
turned  it  in  every  direction  with  ease,  almost  to  the  throat. — 
But  I  may  say,  my  finger  was  hardly  out  of  the  nostril,  ere  the 
tumour  began  again  to  protrude  ;  and  on  the  12th  or  14th  day 
he  had  a  dreadful  haemorrhagy. 

"  There  was  now  no  alternative  but  death,  or  the  most  reso- 
lute operations  :  I  had  not  then  learned  to  use  the  caustic  so 
freely  as  I  now  do,  and  considered  the  partial  application  of  the 
caustic  as  disproportioned  to  the  size  and  rapid  growth  of  these 
polypi.  I  resolved  to  burn,  with  the  actual  cautery,  whatever 
remained  of  these  polypi ;  and  to  give  access  freely  to  their 
roots,  I  noosed  the  polypus,  the  polypus  which  presented,  and 
cleared  the  nostril  a  third  time,  and  had  a  large  cautery,  with 
a  proper  canula,  forged  for  the  occasion.  But  it  was  now  the 
height  of  summer ;  the  weather  towards  the  end  of  July  in- 
tensely hot ;  the  foul  and  pestilent  ichor  which  excoriated  the 
lips  outwardly,  passed  in  such  quantities  into  the  throat,  that  he 
was  seized  with  diarrhoea ;  shiverings,  and  fever  ensued  :  then 
a  state  of  stupor  and  extreme  coldness  succeeded  ;  in  five  days 
he  became  quite  insensible,  and  after  lying  three  days  more  in 
a  state  of  complete  stupor,  accompanied  with  slight  delirium, 
he  expired." 

From  this  narrative  you  will  learn  how  much  more  terrible 
this  disease  is  than  lues  or  cancer  :  for,  with  all  that  is  loath- 
some or  painful,  in  those  diseases,  it  is  attended  with  hemorr- 
hages, stupor,  a  confusion  of  head,  and  affection  of  the  brain, 
which  I  have  always  observed,  is  more  than  hectic  or  haemorr- 
hagy, the  immediate  cause  of  death. 

Since  I  have  represented  almost  every  other  form  and  stage 
of  the  disease,  let  me  represent  this  also,  of  delirium  and  in- 
flamed brain,  brought  on  by  a  rash  and  ill-timed  working  with 
forceps. 

I  have  often  found  the  polypus  advanced  to  its  last  stage  of 
caries,  and  external  abscess,  even  in  the  sixth  month  after  it 
was  first  observed ;  if  not  actually  in  the  sixth  month  of  its 
growth,  and  fatal  within  the  year.  So  it  was  in  the  good 
woman,  whose  death  I  am  now  going  to  describe  :  in  her  case 
indeed  it  would  have  been  so,  although  no  such  rude  operation, 
as  that  I  am  now  going  to  speak  of,  had  been  performed. 

"  G.  T.  a  good  woman  of  forty-five  years  of  age,  was  afflict- 
ed with  polypus,  which  had  long  obstructed  her  breathing  :  for 
half  a  year  or  more,  the  right  nostril  had  been  impervious  ;  dur- 
ing the  three  succeeding  months  she  had  been  deaf,  and  torpid  : 


470  Of  large  and  guttural  Polypi. 

the  tears  flowed  continually  over  her  cheek,  and  the  tooth-acliu 
and  rending  pains  of  the  face  and  head,  became  at  times  dis- 
tracting. The  right  nostril  was  filled  manifestly,  with  a  soft 
and  mucous  polypus,  the  eye  watery  and  inflamed  ;  the  cheek 
suppurated  and  burst,  near  the  can  thus  of  the  eye ;  the  whole 
side  of  the  head  was  pained,  the  cheek  and  jaws  swelled,  soft, 
inelastic,  and  doughy ;  a  purulent  and  thick  matter  flowed 
from  the  suppurated  parts,  at  the  inner  canthus  of  the  eye  ; 
while  a  thin  and  fetid  matter  distilled  from  the  nostril,  and  ex- 
coriated the  lip.  Her  general  head-ach  was  aggravated  by  a 
more  pungent,  and  tooth-achy  pain  in  the  nose  and  jaw  :  yet 
she  seemed  hale,  and  vigorous ;  and  there  appeared  no  reason 
to  fear  such  a  sudden  or  dreadful  catastrophe  from  any  opera- 
tion, however  rude  ;  let  this  case  then,  be  a  warning  to  you. 

"  A  consultation  decided  that  an  operation  was  advisable, 
and  it  was  performed  by  the  forceps.  To  my  apprehension,  no 
polypus  was  extracted :  little  rags,  of  a  soft  and  mucous  mat- 
ter, seemed  to  be  squeezed  by  the  forceps  into  a  mere  jelly  :  the 
forceps  were  used  for  twenty  minutes,  with  no  great  delicacy  ; 
a  small  piece  of  bone  was  found  among  these  rags  of  the  poly- 
pus ;  there  was  not  even  any  remarkable  hsemorrhagy  :  when 
invited  by  one  of  the  attendents  to  look  into  the  largest  portion 
of  the  polypus,  I  found  it  no  other  than  a  roll  of  lint  soaked 
with  blood.  She  was  reported  to  breathe  more  easily  through 
the  nostrils,  but  for  that  slight  and  momentary  relief  she  paid  a 
dear  forfeit. 

w  On  the  day  following  the  operation,  her  pulse  rose  ;  there 
were  manifest  signs  of  an  increasing  pain  ;  the  pain  shot  through 
all  her  head  ;  she  was  hot,  and  thirsty,  with  a  small  and  rapid 
pulse  ;  her  anodyne  draught  produced  no  pleasant  nor  refresh- 
ing sleep. 

"On  the  second  day,  the  nostril,  the  face,  and  eyes,  were 
extremely  painful,  and  the  shooting  pains  and  confusion  of  head 
increased  ;  but  all  this  inflammation  was  internal,  (not  the  less 
dangerous  for  being  so,)  the  eye  and  cheek  were  little  apparent- 
ly affected. 

"  On  the  third  day,  the  heat,  thirst,  rapid  pulse,  and  general 
disorder  within  the  head,  were  alarmingly  increased.  The  sa- 
line draughts,  the  shaving  of  the  head,  and  the  poultice  in  which 
the  whole  face  was  involved,  availed  nothing. 

"  On  the  fourth  day,  at  nine  in  the  morning,  she  was  found 
insensible,  and  remained  so  ;  the  pupils  of  the  eyes  dilated,  the 
breathing  slow,  and  stertorous,  and  the  bladder  paralytic,  so 
that  the  urine  needed  to  be  drawn  off  with  a  catheter. 

"  On  the  fifth  day,  she  lay  in  a  deep  apoplectic  stupor,  had 
no  stool,  passed  no  urine,  was  visibly  sinking;  a  blister  applied 


Of  large  and  guttural  Polypi.  471 

to  the  head  had  its  effect ;  the  sinapisms  also  inflamed  the  soles 
of  the  feet,  but  she  could  not  swallow. 

M  On  the  sixth  day  she  continued  comatose,  sunk  gradually 
duringthe  night,  and  expired  before  morning  :  and  upon  dissect- 
ing the  head,  the  polypus  was  found  a  mere  pulp  of  putrid 
flesh :  the  ethmoid  bone  destroyed  on  the  right  side,  and  the 
vessels  of  the  brain  were  found  turgid  with  blood  ;  its  upper 
surfaces  suffused  with  water,  and  its  lower  surface  in  a  state  of 
suppuration.  Here  are  the  terms  in  which  the  appearances,  on 
dissection,  were  noted  down." 

DISSECTION. 

"  Upon  removing  the  scull-cap,  the  sinuses  and  arteries  of 
the  dura  mater  seemed  to  be  unusually  turgid  with  blood  : 
when  the  dura  mater  was  cut  and  turned  aside,  those  of  the 
brain  were  found  to  be  extremely  turgid  with  blood  :  over  the 
right  hemisphere  of  the  brain,  there  was  an  effusion  of  coagu- 
lable  lymph  ;  on  the  left  side  the  effusion  was  merely  of  serum  ; 
the  ventricles  were  much  distended  with  water  :  the  same  effu- 
sions of  serum,  and  coagulable  lymph  were  found  upon  the  lower 
surface  also  of  the  brain,  and  there  the  dura  mater  was  manifest- 
ly inflamed.  The  cribriform  plate  of  the  ethmoid  bone  was 
gone,  being  entirely  destroyed  by  caries.  The  bones  of  the 
right  side  of  the  r.ose  seemed  all  loose  and  carious  ;  but  all  be- 
low the  ethmoid  bone  within  the  nose,  was  an  indistinct  mass  of 
putrid  and  mucous  flesh  and  bone." 

Having  thus  set  before  you  many  lessons,  and  some  exam- 
ples, and  proved  what  1  have  described,  by  true  drawings,  and 
illustrated  the  operations  I  recommend  to  you  by  plans  ;  I  leave 
you  to  your  own  discretion,  sense,  and  judgment,  reminding 
you  only,  that  this  like  every  tumour,  should  be  resisted  at  an 
early  period  of  its  growth  :  that  these  are  not  maladies  to  be  cur- 
ed by  gentle  and  trivial  practices. 


( w ) 
DISCOURSE  XXIV. 

On  Tumours  of  the  Gums,  Lips,  Cheeks,  and  Throat. 

X  HIS  is,  in  every  sense,  an  arduous  subject;  especially  if  it 
was  my  design,  to  reconcile  every  appearance  of  disease  in  those 
parts,  with  their  complicated  and  curious  structure  :  parts  in 
perpetual  motion,  parts  performing  a  variety  of  functions,  as 
chewing,  swallowing,  speaking,  breathing  :  parts  provided 
with  various  glands,  salivary,  and  lymphatic:  and  secreting 
even  from  their  surfaces,  fluids  of  various  properties.  Surely- 
such  complicated  structure  must  be  a  source  of  various  disor- 
ders ;  for  always  in  the  animal  body,  as  in  less  perfect  machines 
of  human  invention,  no  part  is  so  formed  as  to  serve  various 
purposes,  and  to  perform  many  functions  perfectly.  Reasoning 
from  the  complicated  and  intricate  functions  and  structure  of 
these  parts,  you  would  find  cause  to  believe,  that  their  diseases 
must  be  very  anomalous ;  observing,  on  the  other  hand,  the 
strange  tumours,  obstructions,  and  unnatural  communications 
of  one  part  with  another,  you  would  be  inclined,  as  every  one 
unacquainted  with  our  science  is  accustomed  indeed  to  infer, 
that  the  complex  structure  of  the  parts  about  the  throat  and  jaws, 
is  the  source  of  much  danger  and  misery. 

This  confused  impression  of  complex  structure,  and  propor- 
tioned danger,  was  all  that  struck  me  when  first  I  entered  on 
my  more  mature  and  serious  studies  ;  without  a  hope  of  ever 
arriving  at  any  satisfactory  knowledge  of  subjects  so  slightlv 
mentioned  in  books.  But  time  and  diligence  have  enabled  me 
to  do  something  for  myself,  and  something  for  you.  If  you 
find  in  this  Discourse  no  pleasing  and  delusive  speculation,  you 
will,  I  trust,  find  many  useful  precedents,  and  such  accurate 
dissections,  and  summary  histories  of  diseases,  as  will  induce 
you  to  be  studious,  and  help  to  make  you  superiorly  useful. 

When  we  can  distinctly  perceive,  that  it  is  from  something 
peculiar  in  the  structure  of  a  part  that  diseases  are  frequent  and 
complicated,  precedents  are  very  precious  ;  for  we  are  irresisti- 
bly inclined  to  reason  on  the  cause  of  such  organic  disease  :  and 
it  is  only  under  the  correction  of  plain  facts  and  dissections, 
that  we  can  reason  safely. 

I  must  acknowledge,  while  1  can  no  way  explain  the  fact, 
that  the  gums,  lips,  and  inner  surface  of  the  cheeks,  parts  seem- 
ingly insensible  and  indolent,  give   rise  to  tumours  which  axe 


On  Tumours  of  the  Gums,  &c.  47 o 

indeed  slow,  firm,  indolent,  and  void  of  pain  in  their  early  sta- 
ges, but  in  their  latter  stages,  of  unparalleled  malignity,  assu- 
ming usually  a  fungous  form;  and,  when  the  firm  and  indolent 
tumour  thus  bursts  out  into  a  fungous  efflorescence,  its  growth 
is  so  rapid,  that  I  know  nothing  to  equal  it,  not  even  the  fun- 
gus of  the  brain  !  you  almost  see  it  grow,  and,  when  extirpated 
partially,  it  sprouts  up  again  before  tin  blood  of  such  imprudent 
incisions  is  dried  up.  The  tumours  ol  the  gums  are  spongy, 
luxuriant,  hemorrhagic,  and  truly  cancerous  :  those  lodged 
within  the  substance  of  the  cheek,  knotty,  indolent,  slow,  malig- 
nant, and,  however  long  they  are  of  showing  their  malignant 
nature,  they  terminate,  if  neglected,  (and  much  it  is  to  be  la- 
mented, that,  from  the  patient's  fears,  and  the  surgeon's  timi- 
dity, they  often  are  so,)  in  the  most  incurable  and  desperate 
maladies. 

The  gums  are  subject  to  such  an  infinite  variety  of  slighter 
swellings,  to  boils,  to  little  indolent  tumours  resembling  the 
hordeoli,  or  tumours  of  the  eye-lid,  and  to  harmless  indura- 
tions, that  those  which  are  the  germs  of  the  most  horrible  dis- 
eases, are  too  little  suspicious,  too  slightly  characterised  In-  any 
peculiarity'  of  form  or  aspect  to  attract  attention,  till  too  late. — 
A  small,  firm,  seed-like  tumour  is  perceived,  but  hardly  noticed, 
for  months  ;  it  is  seated  between  two  of  the  lore  teeth,  begins 
to  separate,  displace  and  loosen  them  ;  it  grows  imperceptibly 
and  slowly  :  the  teeth  are  raised  from  their  sockets ;  they  be- 
come loose  and  vaccillating  ;  they  have  no  longer  any  hold  of 
the  jaw,  but  are  merely  hanging  in  the  tumour  ;  the  tumour 
retains  its  original  gristly  hardness  at  its  basis,  becomes  rugged 
and  irregular  in  its  upper  part,  with  a  cockVcomb-like  edge  : 
though  little  painful,  it  bleeds  from  time  to  time  ;  it  extends 
itself  to  the  gums  ot  other  teeth,  whieh  are  successively  displa- 
ced from  their  sockets  and  loosened,  and  one  side  of  the  mouth 
is  occupied  with  it.  Next  the  hard  basis  of  the  tumour  extends 
into  the  cheek  ;  the  tongue  begins  to  be  pushed  aside,  horrible 
fetor  of  the  mouth  ensues,  with  frequent  hemorrhages  ;  the 
tumour  now  protrudes  and  keeps  the  mouth  open  ;  the  disease 
becomes  now  terrible  and  painful,  the  patient  survives  for  a  few 
weeks,  with  the  mouth  and  lower  part  of  the  face  wrapped  up 
in  handkerchiefs,  in  a  miserable  and  loathsome  condition  ;  the 
putrid  and  blackened  blood  distilling  with  the  acrid  saliva 
through  the  filthy  clothes,  till  wasted  by  suffering  he  dies  in 
inexpressible  pain.  Such  is  the  kind  of  death,  from  which,  I 
sincerely  believe  I  have  saved  many  bv  a  slight  incision. 

'*  A  young  Gentleman,  Mr.  H ,  about  25  years  of  age, 

of  an  athletic  form  and  healthy  constitution,  and  without  the 
slightest  taint  of  disease,  hereditary  or  acquired,  had,  from  no 

3  O 


4r4  On  Tumours  of  the  Gums, 

perceptible  cause,  a  tumour  firm,  cartilaginous,  and  elastic, 
seated  so  fairly  in  the  centre  of  the  gums,  as  to  raise  the  two 
centre  teeth  of  the  lower  jaw  from  their  sockets  far  above  the 
general  range  of  the  teeth,  and  separate  the  two  that  lay  adja- 
cent. Gradually,  but  yet  in  a  short  period,  in  a  little  more 
than  three  months,  it  had  separated  those  two  central  teeth, 
projected  from  betwixt  them,  and  increased  to  a  very  remarka- 
ble size  ;  and,  though  it  had  begun  from  the  inside  gum,  the 
greater  portion  seemed  to  be  before  the  gum,  just  over  the  chin, 
projecting  the  nether  lip. 

"  This  tumour  was  about  the  size  of  a  walnut,  irregularly  glo- 
bular, knobby,  and  shining;  when  moved  by  pressing  it  with  the 
thumbs,  backwards  and  forwards,  it  seemed  firm,  fixed,  and 
actually  a  tumour  of  the  jaw-bone  ;  yet  I  knew  it  by  its  smooth 
rounded  form  and  its  elasticity  to  be  a  tumour  of  the  gum.  It 
felt,  when  pressed  between  the  finger  and  thumb,  so  elastic, 
that  a  tyro  must  have  believed  it  to  contain  a  fluid,  while  I 
knew  it  to  be  in  truth  a  solid  tumour,  neither  suppurated,  nor 
capable  of  suppuration.  Its  general  aspect  was  that  of  a  tumour 
so  indolent,  that  nothing  need  be  dreaded  from  it,  and  so  much 
had  it  the  form  of  one  that  might  contain  matter,  than  an  unskil- 
ful surgeon  might  have  been  induced  to  strike  his  lancet  into 
it ;  but  I  was  well  aware,  that  not  a  drop  of  matter  would  follow 
any  puncture  made  into  it,  that  the  tumour  inflaming,  would 
turn  out  its  edges,  spread  into  a  fungus,  and,  in  a  few  months, 
cause  a  horrible  and  melancholy  death. 

"  Dr.  Munro,  Mr.  Allen,  and  myself,  having  consulted  on 
the  nature  of  this  tumour  ;  judging  by  the  analogy  of  former 
cases,  declared  it  to  be  of  a  most  dangerous  nature  ;  it  had 
already  displactd  the  teeth,  probably  injured  the  alveolar  pro- 
cess of  the  jaw-bone,  attained  to  an  alarming  size,  and  threat- 
ened, in  no  long  period  of  time,  to  assume  the  most  malignant 
possible  form  :  we  explained  to  our  patient,  that  it  contained 
no  matter,  was  incapable  of  suppuration,  was  of  a  size  that  for- 
bid all  hopes  of  l'esolution,  was  sure  to  become  cancerous,  ad- 
mitted of  no  delay,  and  we  explained,  that  we  dared  not,  even 
in  its  first  and  least  alarming  stage,  do  less  than  extirpate  it 
irom  the  very  root  :  we  represented,  the  operation  was  harsh 
but  not  tedious,  void  of  danger,  even  of  hsemorrhagy.  That 
nothing  was  to  be  feared  but  the  not  cutting  it  completely  out. 

"  In  preparing  forsuch  an  operation,  it  is  right  to  have  ready 
the  apparatus  of  a  dentist,  especially  forceps  to  twist  out  the 
teeth,  strong  pincers  to  cut  the  solid  gums,  engravers'  knives 
to  cut  away  whatever  is  corrupted  of  the  jaw-bone,  and  pieces 
ot  dry  and  solid  sponge,  to  thrust  down  into  the  void  left  by- 
extirpating  the  tumour,  in  order  to  prevent  hremorrhagy  j  and 


Lipsy  Cheeks  and  Throat.  47 5 

two  things  the  surgeon  must  be  prepared  to  encounter,  great 
difficulty  in  cutting  the  tumour,  and  such  confusion  from  the 
mouth  filling,  like  a  cup,  with  blood,  that,  after  the  first  stroke, 
he  can  see  nothing  of  what  he  does,  but*  must  proceed  by  feel- 
ing. The  surgeon  has  much  reason  to  fear  that,  in  an  opera- 
tion where  his  view  of  the  incisions  is  so  obscured,  he  will  be 
guilty  of  much  unseemly  mangling  and  tearing ;  yet  the  pain 
of  such  an  operation,  however  rudely  performed,  is  nothing 
to  be  compared  with  that  of  pulling  out  a  rotten  stump,  and 
the  motives  infinitely  more  persuasive  than  a  tooth-ach. 

"  In  performing  this  operation,  I  held  the  jaw-bone  firm 
with  the  fingers  and  thumb  of  my  left  hand,  while  my  assist- 
ant inverted  the  lower  lip,  and,  with  a  scalpel  of  special 
strength,  broad-backed  like  a  cartilage  knife,  I  made  the  in- 
cision in  such  a  form  as  to  resemble  the  letter  V,  or  the  Greek 
delta.  The  knife  was  carried  by  the  side  of  each  of  the  dis- 
placed teeth  ;  all  my  strength  of  hand  was  requisite  to  carry 
the  knife  down  to  the  angle  ;  blood  instantly  filled  the  mouth, 
so  that,  after  the  first  stroke  of  the  knife,  every  thing  was  done 
by  feeling  ;  but  I  cut  with  such  decision,  with  such  level  lines, 
and  made  them  so  fairly  meet  each  other  in  the  angle,  that,  by 
pressing  my  two  thumbs,  one  within  side  of  the  tumour,  the 
other  without,  and  pushing  alternately  with  my  thumbs,  and 
poising  with  the  flat  handle  of  the  scalpel,  I  pushed  the  tu- 
mour out,  clean  and  unmangled,  leaving  a  very  wide  opening 
bounded  by  the  fangs  of  the  adjacent  teeth  ;  and,  after  allow- 
ing the  part  to  bleed  till  it  stopped,  I  laid  a  piece  of  sponge  in 
the  deep  triangular  cleft  made  by  the  operation,  and  closing  the 
upper  range  of  teeth  upon  the  sponge,  their  pressure  kept  it  in 
its  place.  This  sponge  was  removed  the  second  day  ;  simple 
dressings  of  dry  lint  rolled  in  the  shape  of  a  pellet  was  substi- 
tuted for  the  sponge  ;  during  eight  or  ten  days  our  patient  ate 
cautiously,  and,  in  little  more  than  ten  days,  the  incision  was 
completely  healed. 

"  I  was  greatly  interested  in  knowing  the  internal  state  of  the 
tumour  in  this  stage  ;  for  I  regarded  this  small  tumour  as  the 
germ  of  that  terrible  disease,  which  I  knew  so  well  by  experi- 
ence, for  which  I  had  operated  sometimes  successfully,  some- 
times at  so  late  a  period  as  only  to  witness,  perhaps  to  accele- 
rate, its  fatal  catastrophe.  There  had,  upon  making  the  incision 
by  the  side  of  one'  of  the  teeth,  appeared  a  little  matter,  but  so 
very  little  as  hardly  to  be  perceptible  in  the  time  of  a  bloody 
incision,  and  not  at  all  to  diminish  the  size  of  the  tumour;  but 
whether  there  was  any  fluid,  purulent  or  gelatinous  in  the  cen- 
tre was  still  doubtful.  In  the  central  parts  were  small  cavities, 
and,    when  they  were  cur   vertically,    a   gelatinous  substance 


•£76  On  Tumours  of  the  Gums. 

oozed  out.  The  internal  surfaces  were  studded  with  small 
grains  like  millet  seed:  the  thickness  and  cartilaginous  texture 
ot  the  coat  ot  this  tumour  formed  by  the  gums,  shews  that  the 
matter  would  havebee*n  long  in  making  its  way  through  thtm  ; 
its  gelatinous  nature  proves  that  the  cavity  would  not  have  clos- 
ed j  the  irregular  surface  studded  with  small  grains  of  a  glan- 
dular nature,  explains  to  us  how  such  a  tumour,  alter  bursting, 
turns  inside  out,  and  degenerates  into  a  granulated  mass  ot 
fungus,  sprouting  in  berrv-like  knobs,  and  little  masses  ot  vas- 
cular granulation.  Whatever  cavity  there  is  in  a  tumour  ot  this 
solid  consistence,  seems  to  me  like  a  calix  ready  to  burst,  and 
turn  out  its  inner  surface,  with  a  new  and  luxuriant  growth  of 
fungu  .  The  dissection  of  such  a  tumour,  having  fleshy  walls 
and  granulated  internal  surfaces,  always  reminds  me  of  the  im- 
prudence of  partial  incisions,  in  consequence  of  which  a  part 
of  the  walls  of  the  tumour  being  left,  the  worst  part  ot  the  dis- 
ease is  left :  a  fungus  sprouting  up  from  the  bottom  of  the 
wound,  is  the  first  intimation  of  the  disease  being  imperlect- 
ly  extirpated,  a  rapid  growth,  hasmorrhagy,  pain,  and,  in  one 
word,  cancer  ensues  :  and  these  are  as  invariably  the  conse- 
quences ot  striking  a  lancet  into  such  a  tumour,  as  of  imperfect 
and  ill-concerted  operations. 

"  This  gentleman  is  perfectly  cm-ed,  the  gums  and  adjacent 
teeth  firm  and  sound,  and  I  confess  I  could  not  reflect  on  the 
structure  of  this  small  tumour,  without  saying  within  myself, 
what  would  have  been  the  state  of  this  tumour  in  three 
months  ?  What  would  have  been  his  condition  in  six  or  eight  ? 
In  its  second  stage,  in  little  more  than  three  months,  it  must 
have  filled  the  mouth  with  a  fetid  bleeding  fungus!  In  eight  or 
ten  months  it  must  have  assumed  the  pertect  character  ot  incu- 
rable, loathsome  cancer.1' 

It  appears  to  me  that,  in  many  cases  which  I  have  been  in- 
volved in,  the  disease  appeared  in  a  more  insidious  form,  no 
circumscribed  tumour,  no  formal  disease  awakening  the  attention 
ot  the  patient,  preceded  the  fungus;  no  suppurated  cavity  open- 
ed, and  turned  its  diseased  surface  out,  in  form  of  fungus  ;  but 
the  mere  separation  of  the  gums  from  the  teeth,  and  alveolar 
process  of  the  jaw,  had  the  same  effect,  for  this  is  the  description 
of  what  I  have  frequently  seen,  and  it  is  exemplified  in  the  fol- 
lowing case  of  a  young  woman  who,  I  fear,  never  recovered. — 
In  this  girl,  not  more  than  twenty  years  of  age,  the  gums  of 
one  or  more  teeth  became  sp- ngy  and  rose  in  jagged  points,  se- 
parating from  the  teeth  :  the  roots  of  these  diseased  parts  of  the 
gum  became  hard  and  tumid,  in  proportion  as  their  jagged 
points  became  more  soft  and  luxuriant ;  the  disease  spread 
trom  gum  to  gum,  till  it  extended  along  the   whole  range  ot 


LtpS)  Cheeks  and  Throat.  4-77 

the  jaw ;  the  whole  substance  of  the  gums  became  thus  spongy, 
thick,  and  fleshy,  rising  into  the  form  of  a  tumour,  of  a  deep 
red  or  liver-colour,  with  a  hard  and  schirrous  basis,  a  bleeding 
surface,  and  cock's-comb-like  edges ;  haemorrhages  burst  fre- 
quently from  the  general  tumour,  while  a  viscid  and  extremely 
fetid  matter  issued  from  about  the  roots  of  the  teeth.  This 
tumour  was  so  vascular,  that  the  teeth,  though  poised  from  the 
sockets,  and  universally  loose  and  vaccillating,  were  almost 
buried  in  it,  and  strong  bridles  of  flesh  extended  across,  from 
that  which  was  external  to  that  which  was  internal,  in  regard  to 
the  range  of  teeth,  through  their  interstices.  To  look  into  the 
mouth,  you  would  imagine  you  saw  it  occupied  totally  with  a 
very  solid  tumour;  when  you  pressed  it  with  the  fingers,  you 
found  it  spongv  and  soft  ;  when  you  tried  it  with  the  probe  you, 
found  it  a  mere  tissue  of  vessels,  through  which  you  could  push 
the  blunt  point  of  it  in  every  direction ;  when  you  felt  for  the 
alveolar  process  with  the  probe,  you  were  conscious  that  the 
bone  was  carious.  By  the  general  aspect  of  such  a  tumour  you 
would  be  deceived,  for  you  would  imagine  it,  especially  in  its 
early  stage,  to  be  nothing  worse  than  a  spongy  intumescence  of 
the  gums,  which  you  might  successfully  clear  away  with  a  scal- 
pel, or  almost  scrape  off  with  a  spoon,  while  it  is,  in  truth,  a 
tumour  so  malignant,  that  I  have  myself  performed,  and  seen 
others  perform,  very  painful  and  very  unsuccessful  operations. 
It  is  one  of  a  character  so  peculiar,  that  I  know  nothing  but  a 
careful  and  early  extirpation  of  it  that  will  prevent  mischief  in 
its  latter  stage,  nor  any  thing  but  a  fair,  open,  and  candid  prog- 
nosis can  protect  the  surgeon  from  obloquy :  be  assured,  that 
when  far  advanced,  it  is  unsubduable  by  the  knife,  cauteries,  or 
caustic  ;  I  have  seen  it,  after  long  continued  antl  cruel  cauteri- 
zing, grow  for  three  months,  the  patient  being  permitted  to  re- 
tire lrom  this  torturing  process  to  the  country,  only  when  hope- 
less and  desperate,  there  to  die  unobserved. 

The  case  which  I  am  now  to  relate  to  you,  is  one  which 
was  confided  to  my  care  too  late  to  serve  any  other  end,  than  as 
a  melancholy  example  of  the  consequences  of  leaving  such  a 
disease  to  run  its  natural  course  ;  a  timely  operation  might 
have  preserved  this  worthy  man  in  health  to  his  iamily. 

"  Mr.  Keil,  of  Monargan,  came  to  town  to  consult  me  late  in 
the  month   of   August,   1802,  after  a  regular  correspondence 

■with  his  attending  surgeons    Dr.  Stewart  and   Mr.  Nimmo 

Though  past  the  prime  of  life,  he  was  a  stout  and  lusty  man, 
healthy,  laborious,  and  active.  His  whole  mouth  was  filled 
with  a  fungous  tumour  of  the  worst  complexion,  wanting  no 
character  of  cancer,  but  that  it  was  void  oi  pain  ;  from  imper- 
ceptible beginnings,  and  by  very  slow  degrees,  it  had  incre;i 


478  On  Tumours  of  the  Gums. 

to  such  a  size  as  to  fill  the  whole  mouth,  press  the  tongue  en- 
tirely to  one  side  :  his  speech  was  embarrassed,  and  his  swal- 
lowing difficult  and  painful,  lor  he  could  no  longer  close  his 
mouth  correctly,  the  tumour  beginning  to  protrude.  The  tu- 
mour was  of  a  deep  red  colour,  irregular,  and  ragged  on  its 
surlace,  luxuriant,  and  of  such  rapid  growth,  that,  in  a  few 
months,  it  had  attained  this  horrible  form:  it  projected  from 
his  mouth,  kept  his  teeth  separate,  raised  those  ol  the  lower 
jaw  from  their  sockets,  so  that  they  (all  those  at  least  of  the 
right  side  of  the  mouth)  stood  high  above  the  range  of  the  ad- 
joining teeth,  and  entirely  loose,  so  loose  that  they  could  be 
picked  out  with  the  fingers,  and  some  of  thefri  were  picked 
away  with  the  fingers  before  the  incisions  were  begun.  The 
tumour  was  void  of  stinging  or  lancinating  pains,  no  rude  pres- 
sure of  the  fingers  excited  any  but  the  ordinary  sensation  ;  it 
was  soft,  spongy,  and  bleeding  in  its  extremities,  or  cock  s- 
comb-like  edges,  solid  and  fleshy  in  its  middle  parts,  and  bul- 
ging and  firm  as  bone  itself  where  it  rose  from  the  jaw-bone  : 
it  was  neither  on  account  of  pain,  dangerous  haemorrhagv,  nor 
fetid  ulceration,  that  the  patient  was  now  thoroughly  alarmed, 
but  by  the  rapid  growth  and  horrible  form  of  the  tumour;  and, 
from  the  increasing  obstruction  in  speaking  and  swallowing,  he 
was  conscious  that  he'  could  not  live,  and  desirous  of  any  ope- 
ration that  might  give  him  even  a  chance  of  surviving,  for  he 
was  satisfied,  there  being  no  blood-vessels,  nor  other  dangerous 
parts  in  the  vicinity  of  this  tumour,  that  the  operation,  though 
painful,  could  not  be  dangerous." 

Opinion-  on  Mr.  Keil's  Case. 

"  Mr.  Keil  cannot  have  witnessed  the  doubts  and  difficulties 
of  his  attending  surgeons,  without  being  aware  of  that  imminent 
danger,  which  it  falls  to  my  lot  to  announce  to  him :  and  my 
duty  and  conscience  equally  incline  me,  to  declare  it  without 
loss  of  time,  and  without  reserve.  A  tumour  so  unusually 
rapid  in  its  growth,  cannot  reiis-'  to  grow,  but  must  continue  to 
extend  the  disease  b\  increasing  the  caries  of  the  jaw-bone,  and 
propagating  the  morbid  action  among  the  surrounding  parts  : 
the  hardened  basis  of  the  fungus  will  soon  -to  the  cheek; 

abscess,  and  indurations  of  the  lymphatic  glands  will  ensue, 
each  ulcer  will  throw  Out  its  fungous  efflorescence,  and  the  dis* 
ease  will  burst  out  upon  the  face  and  angle  of  the  jaw,  with  all 
the  virulence,  and  more  than  the  deformity  ot  real  cancer  ; 
this  resembles  in  its  form  that  fatal  fungus  which  sometimes 
sprouts  from  the  axilla,  after  amputation  of  a  cancerous 
breast,  ■  r  that  which  still  more  frequently   proceeds  from  the 


Lips,  Cheeks,  and  Throat.  479 

spermatic  chord,  after  extirpation  of  the  schirrous  testicle,  and 
which  no  methods,  even  the  most  severe  and  rude  in  surgery, 
have  ever  been  known  to  subdue. 

41 1  am  of  opinion  that,  though  not  accompanied  with  pain, 
nor  as  yet  with  much  fetor,  nor  with  profuse  bleeding,  nor  bear- 
ing the  precise  character  of  cancer,  this  tumour  is  equally  incura- 
ble except  by  the  knife,  and  sure  to  prove  fatal  if  neglected,  (as 
I  tear  it  has  already  been  neglected,)  too  long.  When  I  speak 
in  favour  of  an  operation,  I  must  do  so  with  a  degree  of  resei  ve  : 
I  wish  I  might  propose  it  as  a  sure  resource,  but  the  difficul- 
ties, and  the  chances  of  success  are  so  equally  balanced,  that 
he  would,  in  mv  mind,  be  an  inconsiderate  and  presumptuous 
man,  who  would,  in  these  circumstances,  confidently  promise 
a  cure  ;  but  he  would,  on  the  other,  hand  be  inhuman  and  sel- 
fish in  the  extreme,  who,  for  fear  of  any  reproach  that  might 
attach  to  his  own  reputation,  would  refuse  our  patient  the  only 
remaining  chance  of  life  and  health.  The  terrible  stage  of 
ulceration,  protrusion,  and  haemorrhagy,  and  probably  oi  pain, 
which  is  soon  to  ensue  ;  the  loathsome  and  miserable  condition, 
which  is  inevitably  approaching,  would  be  more  grievous  to  his 
friends,  if,  from  any  want  of  constancy,  we  should  decline  our 
help  ;  and  they  will  feel,  at  some  future  period,  a  degree  of 
self-reproach  for  anv  present  loss  of  time.  But  I  am  beginning 
to  reason  on  moral  feelings  and  duties,  which  belong  to  others, 
when  I  am  expected,  perhaps,  to  deliver  only  my  opinion  on 
the  medical  import  of  the  case.  I  have,  in  the  previous  part  of 
this  letter,  explained  the  grounds  of  this  opinion,  with  unaffect- 
ed deference  to  the  judgment  of  these  professional  gentlemen, 
who,  having  seen  the  beginnings,  and  watched  the  progress  of 
this  disease,  have  had  time  to  reflect  seriously  on  its  nature  and 
consequences.  I  advise  the  operation,  and,  should  this  be  vour 
opinion  also,  and  the  wish  of  our  patient  and  his  friends,  shall 
be  ready  to  perform  it, — the  best  proof  I  can  give  of  the  sincer- 
ity of  my  opinion." 

This  Gentleman,  conscious  of  his  impending  fate,  advised  by 
his  surgeons,  that  this  was  the  only  chance  he  had  for  life, 
without  concealing  that  it  was  but  a  slender  ihance,  gave  his 
consent,  and  became  every  moment  more  anxious  that  it  should 
be  clone  quickly  ;  but  so  critical  was  his  situation,  that  before 
the  necessary  arrangements  were  completed,  a  gland  at  the  an- 
gle of  the  jaw  had  swelled,  an  abscess  there  was  distinctly  per- 
ceived, the  hard  basis  of  the  tumour  had  run  deep  into  the 
cheek,  and,  at  this  most  inauspicious  moment,  when  every 
thing  had  assumed  the  most  unfavourable  aspect  possible,  the 
importunity  of  the  patient,  and  his  friends,  became  very  great, 


480  On  Tumours  of  the  Gums. 

and  I  received  repeated  notes  from  Mr.  Nimmo  requesting  and 
urging  me  to  come. 

Nothing  can  be  more  unpleasant  to  a  surgeon,  who  has  any 
pretensions  to  skill,  than  an  operation  necessary,  mangling, 
cruel,  and  savage  in  appearance,  performed  within  the  mouth, 
beyond  the  sight  of  the  assistants,  and  where  even  the  long  in- 
cisions must  be  guided  by  the  finger,  where  the  dissection  must 
be  irregular,  and  the  whole  must  be  done  blindfold,  from  the 
blood  with  which  the  mouth  is  filled  ;  where  the  best  surgeon 
can  hardly  say  he  is  sure  of  what  he  has  done,  nor  confidently 
think  he  has  cut  away  the  whole  disease.  The  operation  in 
this  case  consisted,  first,  in  picking  away  some  ol  the  loose 
teeth  which  lay  in  the  way  of  the  dissection  :  secondly,  in  a  te- 
dious and  painful  dissection,  by  which  the  tail,  as  I  may  ex- 
press it,  or  a  prolonged  and  firm  part  of  the  tumour,  which 
connected  itself  with  the  cheek,  was  separated  from  its  inner 
surface,  near  the  angle  of  the  jaw,  and  dissected  down  nearly 
to  the  chin  ;  the  cheek  being  reduced  in  all  this  extent  to  ex- 
treme thinness  :  thirdly,  in  a  long  and  direct  incision  guided  by 
the  finger,  which  st  parated  the  firmest  part  or  basis  of  the  tu- 
mour, from  the  whole  length  of  the  jaw-bone,  from  the  angle 
all  round  past  the  chin,  and  nearly  to  the  canine  teeth  of  the  left 
side,  where  alone  the  gum  remained  sound.  Fourthly,  in 
carrying  a  like  incision,  more  dangerous  by  far  in  point  of  hae- 
morrhagy,  round  the  opposite  or  inner  surface  of  the  jaw-bone  : 
fifthly,  in  dissecting  away  the  tumour  from  the  jaw-bone,  from 
the  side  of  the  tongue,  and  from  the  whole  circle  of  the  mouth, 
a  work  not  accomplished  without  frequent  interruptions  from 
hgemorrhagv,  irregular,  and  which  was  performed  by  incisions 
rude  and  mangling  :  and,  finally,  all  the  teeth  of  the  right  side 
of  the  lower  jaw  were  twisted  away  with  the  tumour,  and  the 
bone  scraped  clear  of  all  remains  of  the  fungus,  down  to  that 
decided  line  of  incision,  by  which  the  root  of  the  tumour  was 
separated. 

I  need  not  say  how  careful  I  was  to  make  the  extirpation 
complete  ;  or  how  much  I  risked  in  dissecting  the  cheek,  so  as 
to  leave  merely  the  thickness  of  the  skin,  not  without  a  thou- 
sand anxieties  and  fears,  lest  it  should  slough  off.  1  left  this 
gentleman,  on  the  third  day,  under  the  care  of  Dr.  Stewart  and 
Mr.  Nimmo,  and  am  sure  that  never  were  assistants  more  care- 
ful ol  their  patient,  nor  more  sincerly  interested  in  the  success 
of  another;  his  pastor,  Mr.  Smith,  took  upon  him,  with  the 
most  charitable  disposition,  every  little  arrangement,  nursed 
him,  and  watched  him.  The  part  exhibited  a  promising  appear- 
ance at  one  period,  but  a  dismal,  though  not  unexpected  re- 


Lips,  Cheeks,  and  Throat.  481 

verse  followed,  after  a  few  days  of  retirement  in  the  country, 
he  died  in  a  painful  and  loathsome  condition,  with  this  terrible 
and  fetid  fungus,  protruding  both  from  the  mouth,  and  through 
the  opening  of  the  gland  which  had  suppurated  at  the  angle  of 
the  jaw.  Far  from  being  any  argument  against  the  early  extir- 
pation of  tumour,  the  whole  scene  struck  me  as  a  most  melan- 
choly instance  of  the  danger  of  delay. 

Perhaps  it  is  the  peculiar  structure  of  the  gums,  perhaps  the 
proximity  of  the  bone,  that  gives  this  malignant  complexion  to 
these  tumours;  for  I  have  had  many  occasions  of  remarking  a 
singular  contrast  betwixt  the  malignity  ol  these,  and  their  sud- 
den growth,  after  an  imperfect  operation  ;  and  the  indolent  na- 
ture of  those  of  the  rectum,  though  very  awkwardly  and  imper- 
fectly extirpated.  Sometimes,  though  rarely,  1  have  found 
long  tumours,  like  polvpi,  depending  from  the  walls  of  the  rec- 
tum, protruding  ever}'  time  the  patient  went  to  stool:  and  cre- 
ating inconceivable  irksounness  and  unnatural  pain.  Very  of- 
ten I  find  the  folds  of  the  integuments,  where  they  are  gather- 
ed and  plaited  at  the  opening  of  the  gut,  and  the  glands  with 
which  the  rectum  is  surrounded,  growing  into  ragged  tumours; 
sometimes  of  a  prodigious  size,  fungous  and  loose  in  their 
texture,  swelling  like  a  turkey's  gills,  when  the  patient  strain- 
ed at  stool,  usually  concealed  within  the  rectum,  but  sometimes 
protruding  partially.  But  these  tumours,  formidable  as  they 
may  appear,  I  have  always  found  of  a  mild  character,  void  of 
pain,  attended  only  with  irritation  and  a  sense  of  gravitation  ; 
but  never  ulcerating,  seldom  hemorrhagic,  and  bearing  to  be 
treated  by  every  rough  method,  to  be  tied  with  ligatures,  or 
extirpated  with  the  knife,  or  destroyed  by  caustic,  without 
returning. 

The  history  of  such  a  disease  has  so  little  interesting,  so  lit- 
tle variety  of  circumstances,  that  even  in  the  case  of  a  friend, 
for  whom  I  had  a  particular  regard,  I  found,  after  many  an  anx- 
ious conversation,  nothing  to  mark  but  what  I  have  found  in 
every  case,  viz.  a  tumour  slowly  forming,  indistinctly  perceiv- 
ed at  first,  long  conceived  to  be  merely  an  irritation,  unwilling- 
ly recognized  as  a  tumour,  growing  very  slowly  to  that  size 
which  requires  operation:  protruding  at  each  time  ol  going  to 
stool ;  but  easily  repressed  with  the  finger,  like  a  mere  pro- 
lapsus of  the  rectum,  and  occasioning,  through  many  years,  in 
which  the  patient  was  sensible  of  its  existence,  no  worse  symp- 
tom than  irritation,  and  a  sense  of  gravitation. 

"  M.  D.  a  young  gentleman  of  about  twenty-five  years  of 
age,  had,  if  not  from  infancy,  at  least  from  the  earliest  of  his 
recollection,  a  tumour  in  the  rectum,  which,  every  time  he 
went  to  stool  descended,  so  as  to  leave  a  long  continued  tenes« 

3P 


48ii  On  Tumours  of  the  Gums. 

mus,  with  irksome  squeezings  of  the  sphincter,  and  frequent 
squirts  of  urine  :  but  it  was  easily  repressed  with  the  fingers, 
after  which  the  strainings  ceased.  The  tumour  was  not  pain- 
ful, but  haemorrhages  frequently  burst  from  it,  though  never  to 
a  great  excess  :  it  was  manifestly  of  great  length.  The  head 
or  bulky  and  dependent  part  of  the  tumour  is  extremely  firm, 
and  bolts  out  before  the  faeces  at  each  time  of  going  to  stool ; 
the  stalk  or  pedicle,  is  four  inches  long,  not  that  its  origin  is 
that  far  from  the  opening  of  the  rectum  ;  for  the  neck  is  lax 
and  fleshy,  and  lies,  after  being  pushed  back  within  the  gut,  in 
somewhat  of  a  coiled  or  convoluted  form  :  when  the  finger,  be- 
ing passed  into  the  rectum,  is  laid  along  the  tumour,  a  large 
nutritious  artery  is  felt,  distinctl)  running  the  whole  length  of 
the  tumour,  and  beating  along  the  whole  length  of  the  finger, 
just  as  the  artery  of  the  testicle  is  felt  running  along  the  sper- 
matic chord  ;  a  circumstance,  which  makes  it,  if  not  necessary, 
at  least  desirable,  to  kill  the  tumour,  by  a  ligature  applied  at  its 
root,  and  close  as  may  be  to  the  walls  of  the  rectum. 

"  I  know  no  disappointment  so  provoking,  no  sense  of  awk- 
wardness so  irritating,  as  that  of  miscarrying  in  an  operation 
seemingly  so  simple  as  this:  yet  I  confess  my  sense  of  awkward- 
ness, and  want  of  adroitness,  was  very  unpleasant  to  me.  I 
confidently  expected  to  apply  a  noose,  with  Levret's  tube,  or 
what  is  equivalent,  the  eyed-probe  which  I  sometimes  use 
in  tying  a  polypus  ;  and  it  is  my  duty  to  make  this  confession 
to  you,  that  I  endeavoured  in  vain  to  apply  the  ligature,  by  this 
simple  operation,  to  the  root  of  the  polypus,  and  kept  my  young 
friend  long  under  an  irritating  operation,  in  a  painful  posture. 
But  on  these  occasions,  I  have  by  me  wires,  probes,  and  eyed- 
needles  of  all  shapes  :  I  abandoned  the  intention  of  slipping  the 
noose  thus  over  the  pedicle  of  the  tumour  :  I  threaded  a  long- 
eyed  needle,  mounted  on  a  stalk,  with  a  ligature  of  waxed 
thread ;  I  passed  into  the  rectum  a  lithotomy  conductor,  or 
blunt  gorget,  filled  with  cork  in  its  concavity,  and  introducing 
the  needle,  and  striking  it  through  the  root  of  the  tumour,  very 
close  to  the  walls  of  the  rectum,  I  with  a  common  hook,  run 
along  the  face  of  the  cork,  picked  out  the  ligature  from  the  eye 
of  the  hook,  (a  hook  like  that  is  used  in  aneurism  of  the  thigh 
or  ham,)  drew  it  down,  and  brought  it  out  by  the  anus,  and 
turning  it  over  the  knob,  or  bulky  lower  part  of  the  tumour,  re- 
tracted it  so  as  to  make  the  loop  strangle  the  tumour,  which 
dropt  off  in  a  few  days." 

But  watery  and  yet  very  bulky  and  protuberant  tumours,  en- 
circling the  whole  verge  of  the  anus,  corresponding  in  their 
form,  viz.  three,  four  or  five  tubercles,  with  the  great  lurks 
or  folds  in  skin,  are  infinitely  more  frequent  than  tumours  with- 


Lips,  Cheeks,  and  Throat.  483 

in  the  gut.  Those  tumours  of  the  verge  of  the  anus,  though 
bearing  the  most  formidable  aspect,  rarely  degenerate  into 
cancer  of  the  rectum,  except  in  extreme  old  age,  and  when  irri- 
tated, neglected,  or  disregarded.  But  if  any  thing  can  incline 
the  disease  to  cancer,  or  make  it  alarming,  it  is  the  imperfect 
extirpation  of  it,  or  an  ungainly  attempt  to  kill  it  with  ligature. 
Among  other  varieties  of  this  tumour,  the  following  instance  is 
one  which,  after  being  imperfectly  extirpated,  grew  again  in  a 
few  months  to  twice  its  original  size  ;  after  this  second  growth, 
the  surgeon,  more  anxious  and  more  timid  from  his  ill  success, 
applied  ligatures,  by  which,  far  from  having  strangled  or  killed, 
he  irritated  and  inflamed  them  :  they  had  suddenly  increased 
in  size,  and  he  was  not  a  little  alarmed,  and  doubtful  whether 
to  draw  the  ligatures  firmer,  or  to  extirpate  the  whole  with  the 
knife.  The  subject  was  a  very  hale  and  vigorous  young  man, 
in  the  prime  of  life  ;  though  the  basis  of  the  tumour  was  very 
hard,  and  the  tumours  themselves  towered  to  a  great  height,  I 
found  all  the  verge  of  the  anus,  down  to  the  very  circle  from 
whence  they  arose,  soft,  limber,  and  natural,  as  if  no  such  dis- 
ease were  even  in  its  vicinity.  With  three  or  four  strokes  of 
the  bistoury  I  extirpated  the  whole,  and  cleared  the  verge  of 
the  anus  entirely  of  disease,  or  the  seeds  of  it,  so  that  the  young 
man  continues  now  in  perfect  health  ;  but  to  do  this,  I  spared 
nothing ;  I  pulled  each  tumour  out  with  all  the  strength  of  my 
finger  and  thumb,  and  cut  out  along  with  it  that  part  of  the 
verge  of  the  anus  that  belonged  to  it,  muscular  as  well  as  cuta- 
neous :  to  whatever  depth  the  hardness  extended  I  cut,  introdu- 
cing the  bistoury  quite  within  the  circle  of  the  anus.  Conscious 
that  if  the  operation  should  prove  again  unsuccessful,  the  lad 
could  not  escape  a  miserable  death,  I  cut  away  the  whole  circle 
of  the  anus,  and  have  so  often  cut  away  the  whole,  or  much  of 
the  circle,  without  the  slightest  ill  consequence,  that  I  cannot 
but  admire  the  story  related  in  Keill's  Anatomy,  which,  when  I 
was  a  boy  struck  me  with  so  much  horror  ;  where,  in  speaking 
of  the  verge  of  the  anus,  the  case  is  related  of  one,  who  having 
the  whole  circle  of  the  anus  extirpated  for  piles,  I  believe,  had 
the  anus  so  constricted,  that  he  could  never  after  pass  harden- 
ed fceces,nor  go  to  stool  without  a  glyster. 

Wherever  it  becomes  necessary  to  extirpate  the  whole  circle 
of  the  anus,  I  have  found  it  safe:  the  necessity  of  the  case 
would  vindicate  us ;  but  experience  of  the  little  inconvenience 
it  produces  entirely  reconciles  us.  In  another  case  a  tumour 
of  prodigious  volume,  rolled  out  lump  after  lump,  every  time 
the  patient  chose  to  squeeze  it  down,  and  still  left  great  rolls 
within  the  rectum,  which  could  be  hooked  out  with  the  fingers, 
as  you  would  hook  out  a  pone\  's  tongue  from  its  mouth,  when 


484  On  Tumours  of  the  Gums., 

preparing  to  give  it  a  drench.  From  such  a  voluminous  tu- 
mour, you  may  imagine  the  distress  this  poor  creature  suffered. 
He  was  bv  natural  gruwth,  a  big,  strong,  and  clownish  iellow  : 
by  continual  feeling  of  sickness  and  disease,  he  was  become 
sallow,  and  meagre  ;  and  by  frequent,  1  may  say  incessant, 
diarrhoea,  he  was  greatly  reduced  in  strength  The  sense  of 
pressure  was  inseparable  from  this  enormous  tumour,  whether 
reduced  or  protuberant  ;  and  this  tenesmus  and  straining  so  in- 
cessant, that  twenty  times  in  a  day,  a  pressure,  which  he  could 
not  restrain,  pushed  it  out:  you  may  easily  imagine,  what  un- 
ceasing feelings  he  must  have  suffered,  when  so  voluminous  a 
tumour  was  repressed  within  the  gut. 

Yet  the  character  of  the  tumour  was  singular,  in  being  at- 
tended with  not  the  slightest  pain,  not  a  speck  of  ulceration,  and 
little  haemorrhagy  ;  it  was  soft,  woolly,  lubricous,  and  of  a 
shining  red  like  velvet,  and  as  smooth,  except  in  its  extreme 
edges,  which  were  toothed,  and  scolloped,  like  a  cock's  comb. 
The  whole  mass  of  tumour  might  measure  about  thirty  inches 
in  circumference  ;  it  belonged  to  the  circle  of  the  verge  of  the 
anus  in  such  a  manner,  that  that  circle  was  the  root  ot  the  dis- 
ease, and  the  tumour  could  not  be  extirpated  without  the  whole 
circle  being  cut  out :  and  it  was  so  compressible,  that  when  you 
thrust  the  fore  and  mid  fingers  through  the  centre  of  the  mass, 
into  the  rectum,  your  knuckles,  and  almost  your  hand,  were 
buried  in  the  tumour ;  the  tumour  receding  on  each  side,  and 
allowing  you  to  penetrate  as  deep  with  your  fingers,  as  it  there 
had  been  no  such  disease,  and  you  had  the  consolation  to  feel 
from  within,  that  the  verge  of  the  anus,  a  very  little  way  with- 
in the  circle  was  entirely  free.  This  tumour,  by  far  the  largest 
of  the  kind  I  have  ever  seen,  was  extirpated  by  ligatures,  driven 
through  the  verge  of  the  rectum,  with  a  common  embowelling 
needlf,  passing  it  alternately  from  within  outwards,  and  tying 
each  stitch,  or  round,  as  firmly  as  the  biggest  waxed  ligature 
could  bear  to  be  drawn.  The  whole  operation  was  completed 
at  once  ;  the  whole  of  the  tumour  faded  and  died  at  once  j  the 
patient  was  entirely  and  perfectly  delivered  of  his  disease  ;  and 
the  circle  of  the  anus  was  entirely  extirpated,  the  patient  never 
complained,  nor  even  suspected  the  slightest  inconvenience. 

You  remember  that  I  do  not  profess  to  follow  any  perfect 
order  ;  yet,  if  I  did,  I  know  none  more  natural  than  to  arrange 
with  tumours  of  the  gums  those  of  the  cheek  ;  or  to  compare 
the  diseases  of  adjacent  parts,  especially  where  their  constitu- 
tion, form,  surface,  and  internal  texture,  their  glands,  exha- 
lents,  and  other  apparatus  of  secretion,  in  short,  their  entire 
structure  is.  similar  ;  and  where  by  a  very  allowable  inierence, 
their  diseases  may  be  expected  to  be  allied.     So  it  is,  I  believe, 


Lips,  Cheeks,  and  Throat. 


485 


with  the  cheeks  and  the  gums,  where  the  schirrous  indurations 
of  the  early,  and  the  cancerous  excrescences  and  fungi  of  the 
latter  stagers,  are  so  extremely  similar,  and  where  there  are  but 
a  few  special  differences,  which  are  easily  described. 

The  cheek  is  a  part  where  no  conspicuous  gland,  (the  parotid 
and  the  socia  parotidis  excepted,)   are  known  to  exist  ;  and  yet 
the  tumours  I  am  now  to  describe,  are  plainly  not  diseases  of 
cellular  substance,  nor  of  the  secreting  surface,  but  assume  very 
early,  and  al\va\  s  before  they  arrive  at  ulceration,  a  knobulated 
and  glandular  form  ;  where,  the  first  knot  or  kernel  is  plainly 
glandular,  and  where  the  tumour,  when  it  becomes  irregular, 
and  threatens   cancer,    plainly    is    so,  being  irregular,   by   the 
spreading  of  the  disease  from  gland  to  gland.     I  know  no  dis- 
ease which  I  stand   more  in  awe  of, 'and  chiefly  I  fear  it  from, 
these  considerations,  that  it  is  rarely  mild  or  stationary,  almost 
always  progressive  towards  something   more    alarming  ;    find 
either  the  tumour  is  seated  so  much  in  the  centre  of  the  cheek, 
and  so  adheres  to  the  inside  membrane,  as  to  make  it  difficult 
to  extirpate  it,  for  fear  of  making  a  large  opening  there  ;  or  by- 
being  seated  further  back,  is  so  entangled  with  important  ves- 
sels and  nerves,  as  to  make  the  extirpation  a  matter  too  critical 
to  be  attempted  lightly.     This  is  a  disease  of  the  most  insidious 
nature,  so  slow  in  its  growth  that  we  are,  from  its  long  dura- 
tion, diverted  from  any  sense  of  danger  ;   I  have  known  it  ex- 
ist for  twenty  years,  and  even  from  infancy,  without  assuming 
a  threatening  aspect ;  when  all  at  once,  without  any  sensible 
cause,  it  has  shown  its  malignant  nature.     VVhile  \ou  are  en- 
couraging your  friend  or  patient  with  hopes,  that  the  tumour, 
which  he  cannot  but  think  of  at  times  with  apprehension,  is 
mild  in  its  nature,  it  grows  suddenly  hard,  reddens,  ulcerate'. 
and  becomes  cancerous.     Or  when  you  have  extirpated  the  tu- 
mour, and  dismissed  your  patient,  confident  in  his  sound  condi- 
tion, and    self-contented   in  respect   to    what  you  have   done, 
when  you  have  long  forgotten  the  operation,  and  the  patient, 
and  can  hardly  prevail  with  yourself  to  believe  that  a  disease  s<> 
extirpated  can  return,  letters  come,  announcing  to  you  that  it 
has  grown  again.     Various  inexpressible  circumstances,  of  con' 
sistence,  colour,  and  form,  intimate  to  the  surgeon  the  lurking 
danger.     The  tumours  which  I   most  dread,  are  those  seated 
in  the  centre  of  the  cheek,  deep  within  its  substance,  connected 
at  once  with  the  inside  membrane,  and  with  the  skin,  not  move. 
able,  firm,  glandular,  hard  in  their  general  substance,  and  irre. 
gular  in  their  form,  knobulated,  and  having,  as  a  sort  ot  centre, 
some  one  or  more  globular  masses,  also  very  firm,  but  which, 
in  place  of  being  hard,  have  a  sort  of  elasticity  which  gives  tru*. 
conception  of  their  having  cartilaginous  walls  of  extreme  thick- 


486i  On  Tumours  of  the  Gumsy 

ness,  containing  a  small  proportion  of  gelatinous  matter.  And 
in  truth  it  is  so  ;  these  central  globes  are  found  usually  to  con- 
tain a  gelatinous  fluid  :  but  sometimes,  nay  frequently,  a  thick 
and  gelatinous  blood,  partly  clotted,  partly  fluid.  Such  a  tu- 
mour is  extremely  slow  in  its  growth,  but  is  still  growing  ;  lit- 
tle painful,  but  yet  communicating  a  general  sense  of  tooth-achy 
pain,  or  shooting  ;  sensibly  aggravated  in  moist  weather,  or 
east  winds  ;  and  it  is  usually  covered  with  a  coarse  and  granu- 
lated skin,  very  thick  and  porous,  like  that  of  a  lemon,  firmly 
attached,  in  a  considerable  extent,  to  the  surface  of  the  tumour, 
and  incorporated,  as  it  were,  with  the  substance  of  it ;  this  ad- 
hesion of  the  skin  is  ever  a  sign  of  danger. 

Of  such  tumours,  I  shall  lay  before  you  various  examples, 
not:  uninstructive,  with  operations  sometimes  fortunate,  some- 
times unsuccessful  :  nor  shall  I  be  so  unmanly  as  to  conceal 
from  you  the  cases  in  which  I  have  been  unfortunate,  especially 
•where  the  ill  success  may  be  imputed  to  any  want  of  skill  or 
conduct,  for  every  such  avowal  must  be  invaluable  to  you. — 
No  man  can  be  always  wise,  nor  always  fortunate  ;  he  who 
pretends  to  unvaried  success,  is  either  a  knave  or  a  fool.  I 
take  especially  pleasure  in  laying  before  you  a  case  where  this 
species  of  tumour  was  strongly  characterized  ;  win  re  it  existed 
perhaps  from  birth,  certainly  from  early  childhood  ;  where  the 
operations  were  such  as  I  could  not  enter  upon  without  reluc- 
tance, nor  perform  without  encountering  various  difficulties. — 
In.  the  first,  I  fear,  a  slight  fault  on  my  part  proved  the  occasion 
of  great  pain,  and  danger  to  my  patient,  of  a  weary  journey, 
and  a  second  operation ;  the  recollection  of  which,  though 
painful  to  me,  may  be  useful  to  you  ;  and  this  I  feel  to  be 
tile  surest  way  of  restoring  myself  to  placid  and  approving 
thoughts. 

"  Mr.  Taylor,  a  tall  and  slender,  but  strong  and  active  man, 
not  exceeding  thirty  years  of  age,  was  afflicted  with  a  tumour, 
^hich  had  indeed  existed  from  his  earliest  years,  but  had  in- 
creased lately  with  alarming  rapidity  ;  assuming,  at  the  same 
time,  so  malignant  an  aspect,  that  all  those  whom  he  consulted 
(Jeclared  it  dangerous,  wished  that  it  might  be  extirpated,  but 
declined  performing  an  operation  attended  with  so  many  dif- 
j&culties.  In  this  disturbed  and  agitated  state  of  mind,  he  tra- 
velled from  a  remote  part  of  Ireland  to  commit  himself  to  mv 
<:are.  The  indolence  of  this  tumour  from  chddhood  upwards, 
iits  sudden  increase  of  growth,  from  imprudent  and  violent  ex- 
ertions, its  hard  irregular  form,  the  coarse  and  porous  skin  with 
ivhich  it  was  covered,  the  firmness  with  which  it  adhered  to 
either  surface,  viz.  to  the  skin  of  the  cheek,  and  to  the  mem- 
brane of  the  mouth  ;  the  redness  it  contracted,  and  the  shooting 


Lips,  Cheeks,  and  Throat,  487 

pains  which  began,  towards  the  latter  stage  of  the  disease  j  the 
manner  also  in  which  it  was  consolidated  into  one  substance 
with  the  whole;  chm-k,  and  the  apparent  impossibility  ot  extir- 
pating it  without  cutting  actually  the  cheek  itselt  away,  were 
circumstances  particularly  worthy  of  attention.  This  tumour, 
he  was  well  assured,  had  existed,  if  not  from  his  birth,  at  least 
from  his  early  infancy,  in  the  form  of  a  small,  firm,  kernelly  tu- 
bercle, seated  within  the  substance  of  the  cheek,  not  far  from 
the  angle  of  the  nose  ;  nor  can  he  recollect,  during  all  the  peri- 
od of  his  youth,  or  manhood,  any  circumstance,  either  of  pain, 
swelling,  or  change  of  colour,  which  called  his  attention  to  this 
tumour,  much  less  alarmed  him.  He  had  arrived  at  his  thir- 
tieth year,  when  suddenly,  in  consequence,  of  violent  exercisie, 
in  very  sultry  weather,  and  in  the  open  air,  he  observed,  first, 
slight  and  transitory  pains  in  the  tumour  ;  but  such  as  nev<;r 
would  have  alarmed  him,  had  he  not  been  wakened  from  this 
supine  and  unreflecting  state  of  mind,  by  a  manifest  and  sudden 
increase  of  size.  Then  he  thought  of  rubbing  the  part  with 
mercurial  ointment,  and  applied  to  his  brother,  who  is  of  our 
profession,  for  his  advice.  Then,  for  the  first  time,  he  began 
to  feel  all  the  unhappiness  of  a  man  in  danger  of  cancer,  and 
doubtful  whether  even  the  severest  operation  could  afford  him 
relief  ;  and  with  all  the  agitation  of  one  occupied  with  such 
dismal  reflections,  he  consulted  every  one  who  was  accessible 
to  him,  and  still  as  he  passed  through  the  country  sought  new 
counsel,  and  every  where  he  had  the  unhappiness  to  find,  that 
his  disease  was  regarded  as  desperate,  and  the  operation  as  bare- 
ly practicable. 

"  Six  months  had  now  elapsed,  from  the  time  of  this  con- 
spicuous increase  of  size  ;  the  tumour  had  attained  to  more 
than  twice  its  original  bulk:  there  had  been  an  accretion  of  many 
lesser  lumps  to  the  main  body  of  the  tumour ;  in  little  more  in- 
deed than  three  weeks,  the  tumour  had  increased  to  four  times 
its  original  size,  the  pains  were  become  more  pointed  and  fre- 
quent, he  was  obliged  to  be  careful  of  it,  and  preserve  it  like  a 
part  affected  with  tooth-ach  or  rheumatism,  from  cold,  and 
the  vicissitudes  of  the  air  ;  and  in  damp  weather  or  severe 
cold,  he  was  tortured  with  pungent  htat  and  shooting  pains,  the 
heat  and  shooting  pains  being  peculiarly  felt  in  that  part  of  the 
tumour  which  was  most  conspicuously  increasing  in  size. 

"  But  if  those  shooting  pains,  and  this  sudden  increase  of 
size  were  ominous,  the  change  which  next  ensued  was  more 
perplexing,  and  alarming  ;  for  on  its  internal  surface,  it  began 
to  connect  itself  not  only  with  the  inside  surface  of  the  cheek, 
but  with  the  substance  of  the  gums  :  an  irregular  excrescence 


488  On  Tumours  of  the  Gums. 

projected  into  his  mouth,  which  he  compared  with  a  claw  or 
horn,  and  of  such  length  and  bulk,  that,  being  checked  by  the 
teeth  during  sleep,  it  was  torn  away  with  a  considerable  effu- 
sion of  black  and  fetid  blood.  On  the  external  surface  of  the 
cheek,  the  skin  thickened,  became  porous  and  coarse,  adhered 
to  almost  the  whole  extent  of  the  tumour,  was  puckered  and 
pursed  up,  at  the  place  where  the  lesser  glandular  lumps  were 
grouped  and  knotted  round  the  chief  body  of  the  tumour,  which 
was  very  nearly  in  the  centre  of  the  cheek. 

r  Alarmed  by  such  decisive  changes  in  the  character  of  the 
tumour,  he  called  upon  a  Dr.  Henry,  who  had  promised  to  per- 
form the  operation,  but  he  now  expressed  his  reluctance  on 
account  of  certain  blood  vessels,  especially  of  the  infra-orbi- 
tary  nerve  and  artery,  which  he  feared  would  retire  into  their 
hole  under  the  cheek  bone,  before  the  artery  could  be  secured 
This  discouraging  suggestion,  and  an  express  declaration  that 
the  tumour  was  of  a  schirrous  nature,  induced  Mr.  Taylor  to 
apply  to  a  number  of  gentlemen  who  told  him  of  the  danger  of 
the  disease,  of  the  difficulty  of  the  operation,  and  the  prudence 
of  coming  directly  to  this  city. 

"  My  patient  was  of  a  pale  complexion  and  melancholy  tem- 
perament, and,  after  a  journey  so  cheerless  and  inauspicious, 
where  he  was  told  at  every  step  the  danger  of  this  disease,  and 
the  difficulty  of  that  operation  from  which  alone  he  could  ex- 
pect relief,  he  was  too  unhappy  and  dejected  to  receive  any 
consolation  from  my  assurances.  The  tumour  was  not  of  that 
size  to  be  esteemed  monstrous  in  any  glandular  or  fleshy  part, 
but  it  was  great  in  proportion  to  the  part  in  which  it  was  seated, 
it  was  of  a  stony  hardness,  firmly  connected  with  the  substance 
of  the  cheek,  of  a  globular  form,  and  surrounded  by  small  sub- 
sidiary tumours,  seemingly  of  a  glandular  nature,  firmly  con- 
densed and  mixed  in  their  substance  with  the  main  tumour  and 
with  the  substance  of  the  cheek.  The  skin  was  thick,  with  gaping 
pores,  a  coarse  granulated  texture,  and  a  very  firm  adhesion  to 
all  the  tumour,  except  its  very  apex  ;  and,  in  the  centre  of  this 
granulated  skin  were  livid  tubercles,  about  the  size  of  a  boy's 
marble,  extremely  hard  in  their  substance,  and  of  a  very  omi- 
nous appearance  ;  and  where  these  projected  a  little  below  the 
centre  of  the  cheek,  the  skin  was  puckered  and  drawn  in. — 
While  the  external  surface  was  thus  connected  with  the  skin  of 
the  cheek,  so  as  to  draw  the  angle  of  the  mouth  obliquely  up- 
wards, the  internal  surface  was  very  dangerously  attached,  not 
only  to  the  inner  surface  of  the  cheek,  but  to  the  gums  :  the 
inner  surface  of  the  cheek  felt,  upon  introducing  the  finger,  tu- 
berculous, and  rugged,  and  extremely  hard  ;  and  the  tumours, 
when  felt  from  within,  appeared  distinctly  to  be  the  sum'.-  inclu- 


Lips,  Cheeks,  and  Throat.  .   4S9 

rated  schirrous  substance  which  projected  from  the  external 
substance.  Upon  inverting  the  cheek,  these  tubercles  were 
seen  knotty,  irregular,  and  rugged  like  piles,  or  like  those  vene- 
real warts  of  the  anus,  which  are  termed  fici.  Where  this  dis- 
eased substance  approached  the  angle  ot  the  nose,  it  adhered 
very  firmly  to  similar  tubercles  springing  from  the  gums,  and 
the  shooting  pains,  now  severe  and  constant,  together  with  the 
dejected  appearance,  and  sallow  complexion  of  Mr.  Taylor, 
joined  to  the  united  opinion  of  many  ot  our  profession,  could 
not  fail  to  impress  me  with  a  confirmed  apprehension  of  its  ma- 
lignity ;  but  that  only  inspired  me  with  a  greater  desire  to  give 
him  the  only  chance  of  life. 

"  In  respect  to  the  projected  operation  no  circumstances 
could  be  more  discouraging  than  those  I  have  just  described  : 
I  was  conscious  that,  in  attempting  to  save  him,  I  must  not 
merely  extirpate  a  tumour  by  nice  dissection,  but  cut  through 
the  cheek  and  dissect  away  almost  all  its  substance  ;  that  I  must 
divide  the  facial  artery  below,  and  the  transversalis  faciei  com- 
ing from  the  temple,  and  the  labial  artery  returning  from  the 
lip  ;  that  I  must  not  merely  wound,  but  cut  away  the  salivary 
duct,  and  lay  the  whole  side  of  the  tace  open,  making  a  breach 
larger  than  the  mouth  :  it  could  not  but  seem  problematical, 
whether,  after  such  an  operation,  the  saliva,  or  food,  could  ever 
be  retained  again,  whether  the  attempt  would  not  involve  me  in 
disgrace,  whether  I  should  not  be  blamed  deeply  for  adventu- 
ring on  that  operation  which  so  many  had  declined.  But  1  was 
emboldened  by  this  recollection,  that,  often  by  a  grape-shot,  or 
by  a  splinter  in  battle  at  sea,  the  whole  cheek  is  carried  away, 
and  sloughing  succeeds  to  immediate  loss  of  substance ;  that  I 
had  every  reason  to  believe,  though  much  of  the  substance  of  the 
cheek  must  be  cut  away,  I  should  be  able  to  bring  together  the 
remaining  skin  of  the  cheek  ;  I  most  ot  all  considered  that  this 
gentleman  had  travelled  from  a  distant  country,  and,  leaving 
behind  many  skilful  and  dexterous  surgeons,  came  to  commit 
himself  with  resignation  and  confidence  into  my  hands,  that  I 
owed  him  some  sacrifices  in  return,  and  that,  unless  I  attempt- 
ed to  save  him,  he  must,  at  no  remote  period,  die  of  cancer  ;  I, 
therefore,  prepared  myself  tor  the  operation." 

The  hooks,  knives,  and  forceps  necessary  for  such  a  dissec- 
tion being  properly  disposed,  with  needles  for  tying  the 
arteries,  1  proceeded  with  an  operation  which  could  not  tail 
to  be  extremely  slow,  since  its  principal  purpose  was  to  dis- 
sect out  the  whole  disease,  and  save  as  much  as  possible  the 
sound  parts. 

I  drew  mv  knife  in  the  direction  of  that  line  of  feature  which 

3   Q 


490  On  Tumours  of  the  Gums, 

marks  the  levator  anguli  oris,  and  surrounded  the  tumour  with 
a  second  incision,  like  the  first  ;  but,  approaching  very  closely 
the  angle  of  the  mouth,  I  proceeded  to  dissect  away  the  tumour 
from  it,  and  from  the  jaw-bone,  and  thought  it  singular,  that  the 
labial  artery  where  it  approaches  the  lip,  and  the  facial  artery 
where  it  turns  over  the  angle  of  the  jaw,  were  so  elongated 
without  being  divided,  that  I  slipta  ligature  under  each  of  them 
with  the  needle,  without  pricking  even  the  cellular  substance, 
and  tied  them  before  cutting  them  across. 

Having  turned  the  tumour  upwards,  I  cut  through  the  inside 
membrane  of  the  mouth,  cut  clean  away  the  tuberculous  promi- 
nences of  the  gum,  dissected  upwards  towards  the  eye  ;  and, 
when  much  of  the  tumour  was  detached,  regarding  the  infra- 
orbital nerve  as  the  most  important  and  painful  part  of  the 
dissection,  I  reserved  this  as  the  last  stroke,  and  while  I  dissect- 
ed this  part,  and  especially  when  I  cut  the  nerve  across,  the 
suffered  an  intensity  of  pain  which  made  him  quite  savage,  it 
was  then  only  that  he  stamped  with  his  feet  and  cried  out  in 
agony.* 

*  T  have  always  obferved  thatthe  cutting  acrofs  a  nerve  produces  an  inconceiva- 
ble fhock  and  of  this  nerve  efpeciaily  a  dreadful  pain,  which  is  on  no  occafion  fo 
manifeft,  as  when  the  operation  of  cutting  acrofs  the  nerve  for  the  cure  of  the  tic- 
douleureux  is  performed  ;  for  then  the  cutting  acrofs  the  nerve  is  complicated  with 
no  other  incifions  to  confound  the  fenfation.  which  is  at  once  fo  peculiar  and  fo 
alarming,  that  the  patient  leels  as  if  fhot,  and  ftarts  up  in  agony  inexpreffible  ; 
and  this  firfl  fenfation  is  inftantly  followed  by  a  pleafing  calm  and  a  happy,  and 
perfect  relief  from  pain.  Thofe  whom  I  have  feen  labouring  under  this  fingulai 
nervous  difeafe,  have  had  the  affected  fide  of  the  face  reddened,  the  cheek  con- 
vulfed,  the  lip  quivering,  and  the  eyes  filled  with  tears  from  the  intenfity  of 
pain.  One  old  man  about  70  years  of  age,  who  was  cured  in  an  inftant  of  a  dif- 
eafe of  many  years  duration,  by  my  worthy  and  much  refpected  friend,  Mr.  Har- 
rifon,  of  Ulverfton,  had  this  convulsion,  and  trembling  of  every  feature,  in  a  An- 
gular e'egree.  Another  old  gentleman,  Capt.  G.  of  R— — ,  in  Iverncfhire,  had 
this  inceffant  trembling  of  every  leature,  as  if  each  mufcular  fibre  of  the  face  had 
been  ftruggling  in  an  indetermined  condition,  betwixt  convulfion  and  paralyfis ; 
and  this  convulfion  was  accompanied  with  fuch  agonifing  pains,  and  wild  and 
piercing  cries,  as  actually  alarmed  the  ftreet  in  which  he  lived  :  but  I  fhall  de- 
fcribe  his  condition  in  his  own  words,  as  di&ated  to  my  affiftant  Mr.  Allan  : 
Capt.  G.  was,  at  the  period  of  the  operation,  about  75  years  of  age. 

"  One  afternoon,  about  eleven  years  ago,  while  fitting  at  dinner,  I  was  fuddci 
ly  and  feverely  attacked  with  fharp  and  thrilling  pains.beginning  at  the  root  of 
the  wing  of  the  nofe,  extending  all  over  the  right  fide  of  the  face,  centering  in  the 
cheek,  but  fhooting  in  a  particular  manner  upwards  by  the  corner  of  the  eye  into 
the  temple  .  the  fit  was  momentary,  but  the  cheek,  the  lips,  and  eye-lids  quiver 
cd,  and  were  convulfed. 

"  From  this  time  I  have  been  always  fubject  to  this  torturing  difeafe,  which  has 
been  the  occafion  of  various  journies  to  town,  and  innumerable  confukations  :  my 
fufferings  fometimes  intermitted  for  weeks,  during  which  I  was  almofl  entirely 
free  from  pain,  and  often  again  I  fuffercd  fix  or  fevec  severe  paroxyms  of  convul- 
fion and  pain,  in  one  day,  and  as  many  during  the  night  •  I  was  for  two  years 
contented  with  the  advice  of  my  furgeons  in  the  country,  who  prefcribed  blifters 
and  many  other  applications  both  fevere  and  trivial,  but  with  fo  little  good  effect 
that  they  afcribed  my  diforder  to  worms  in  the  cavity  of  the  upper  jaw.  About 
two  years  after  the  firft  attack,  my  difeafe  aflumed  a  more  determined  form  and 


Lips,  Cheeks,  and  Throat.  491 

The  tumour  being  removed,  the  gap  which  was  made  seem- 
ed horrible,  even  to  me.       The   side  of  the  face  was  open,  the 

returned  in  paroxyfms  with  a  degree  of  regularity  :  after  a  lapfe  of  two  nrvec 
months,  it  would  return  for  an  equal  period,  and  continue  to  torture  me,  foQfet 
my  appetite  and  fleep  left  me,  my  memory  even  fecrrted  affected,  and  my  general 
health  fuflfered. 

"About  four  years  ago  I  came  to  Edinburgh,  and  put  myfelf  under  the  care  of 
a  furgeon  of  diitinguifhed  reputation,  confulting,  at  the  fame  time,  Dr.  Gregory 
Grant;  and,  by  their  conjoined  advice,  i  had  the  gums  of  my  upper  jaw  fcari- 
fied,  and  three  or  four  of  my  grinders  extracted  ;  and,  after  remaining  fonie 
weeks  under  their  care,  1  returned  home  feemingly  well,  and  felt  nothing  of  my 
difeafe  till  about  the  third  month,  alter  the  fcarifying,  and  the  extraction  of  my 
teeth,  when  fuddenly  it  returned  in  all  its  violence,  and  continued  to  diilract  mc 
lor  two  years  more. 

"  At  the  end  of  two  years  '  was  again  driven  to  town  by  this  diffracting  mala- 
dy, and,  having  put  myfelf  under  the  care  of  the  fame  gentleman,  and  having 
called  Dr.  Monro  into  confutation,  he  directed  that  the  only  remaining  grinder 
on  that  fide  of  the  upper  jaw  fhould  be  pulled,  and  I  was  then  fent  home,  but 
without  the  flighteft  alleviation  of  my  dilbrder,  which  I  endured  for  two  years 
longer. 

"  About  three  weeks  ago  I  arrived  in  town  a  third  time,  and,  after  a  very  formal 
and  numerous  confultation,  it  was  refolved,  to  try  the  experiment  of  cutting 
acrofs  that  nerve  which  partes  under  the  eye  to  the  face  :  my  agonies  were  now 
fo  dreadful,  and  unremitting,  that,  often  I  was  obliged  to  ftart  up  from  table,  and 
could  not  refrain  from  cries  and  howhng,  fuch  as  were  but  too  diftinctly  heard 
in  the  ftreets.  The  operation  was  accordingly  performed  by  one  of  thofe  gentle- 
men, who  made  the  incifion  you  fee  beneath  the  eye  :  for  fome  time  I  flattered 
myfelf  I  had  derived  all  the  benefit  that  was  promifed  mc,  and  even  when  my 
pains  returned,  I  was  over-perfuaded  that  thofe  were  the  flight  remains  of  a 
defperate  difeafe,  and  would  be  tranfient.  In  thisperfuafion  I  had,  I  may  fay,  be- 
gun my  journey ;  I  had  got  into  the  poft-chaife  which  was  to  convey  me  from 
town,  when  I  was  l'cized  with  a  paroxyfm  fo  agonizing,  fo  very  dreadful,  that  I 
was  carried  back  into  the  inn,  and  have  now  refumed  my  place  in  lodgings,  to 
ommit  myfelf  to  vour  care. 

"  April,  1804."' 

I  doubt  not  the  reafon  of  the  tic  dolcureux  returning,  U  ofren  like  the  ill 
tuccefs  of  vaccine  inoculation,  to  be  afcribed  to  the  manner  in  which  the  opera- 
tion is  performed.*  The  performing  of  this  nice  and  delicate  ftxoke  of  the 
knife  was  probably  confided,  in  this  cafe,  to  a  gentleman  whofe  fir  ft  and  only 
diffeetion  of  nerves  had  been  in  the  living  fubjet? ;  his  ill  fuccefs  was  fufficient 
warrant  for  this  conclufion  ;  it  was  impoffible  for  an  anatomift  to  look  at  the 
icar  of  his  incifion,  without  an  inftant  convidtion,  that  it  did  not  at  all  crofs  the 
courfe  of  the  mfra-orbitary  nerve  ;  deceived  by  the  baggy  eye  of  a  man  advan- 
ced in  years,  and  feeling  only  for  the  margin  of  the  focket,  he  had  carried  a 
long  incifion  in  the  direction  of  the  natural  lurk  of  the  fkin,  and  certainly  could 
much  only  the  rim  of  the  focket ;  it  is  far  below  this,  that  the  nerve  lies  in  a  deep 
hollow  :  my  education  and  my  experience,  put  me,  I  believe,  far  above  the  pue- 
rile vanity,  and,  I  hope,  above  the  fufpicion  of  magnifying  beyond  the  truth, 
this  trivial  fuccefs ;  I  could  not  but  know  the  infra-orbitary  nerve  a  little  better 
i  ban  my  predecefTor,  and  could  not  fail  to  cut  it.  I  feated  my  patient  in  a  chair, 
and,  preffing  the  point  of  my  fore  finger  deep  into  the  hollow  where  the  nerve 
lies, cut  it  acrofs,  by  finking  in  a  {mail  fharp-pointed  knife,  making  no  length  of 
outward  incifion,  :  nd,  hooking  the  point  oi  tlie  crooked  biftoury  behind  the  nerve  ; 

m  the  very  inftant   of  the  ftrokc  by   which  it  was  divided,  Capt.  G ftarted 

rom  his  feat,  ran  forwards  in  great  confufion,  exclaiming,  "  Good  God!  what's 

*  The  tic  dolcureux  h~s  returned  after  the  operation  has  been  performed  by  the 
-irft  furgeons  both  in  France  and  England.     It  has  f   netiraes  been  cured  by  the 

S. 


492  On  Tumours  of  the  Gums, 

range  of  teeth  in  both  jaws  quite  exposed,  in  spitting  out  the 
blood  it  issued  through  the  cheek, and  the  tongue,  when  he  turn- 
ed it  that  way,  passed  through  the  opening,  not  through  the 
mouth,  but  through  the  under  opening  of  the  cheek,  so  that  my 
assistant  found  it  right,  to  prevent  the  alarm  of  the  patient,  and 
decent  in  regard  to  the  spectators,  to  purse  the  parts  together, 
and  cover  them  with  his  hand:  in  short,  it  was  such  an  appear- 
ance as  you  would  willingly  hide  Irom  yourself. 

But  it  was  a  pleasure  to  see  how  nicely  the  parts  fell  together, 
when  smoothed  down  with  the  palm  of  the  hand,  and  how 
little  they  were  pursed  when  sewed.  I  make  it  a  rule  in  all 
mv  operations,  to  let  even  the  oozing  of  blood  cease  before  I  lay 
the  parts  together;  having  allowed  some  time  to  elapse,  I  pro- 
ceded  thus:  first,  taking  the  edge  of  the  buccinator  muscle, 
much  of  which  I  had  saved  in  the  dissection,  I  raised  it  towards 
the  cheek-bone,  sewed  the  edge  of  the  muscle,  to  the  rags  of 
the  inside  membrane  of  the  mouth,  and  to  the  strong  cellular 
and  muscular  substance,  under  the  most  prominent  part  of  the 
cheek-bone,  and  carrying  the  thread  inwards  and  tying  it  on  the 
inside  of  the  mouth,  I  there  cut  it  quite  short,  resolving  never 
to  look  after  it,  but  leave  it  to  suppurate  out.  Next,  I  passed  a 
deep  stitch  through  the  upper  part  of  the  incision,  where  force 
was  required  to  bring  the  parts  in  contact  or  to  hold  them  so 
there;  in  the  hollow,  I  meant  to  lay  a  soft  and  large  compress. 
But  the  lower  and  central  parts  of  the  incision,  where  the  flaps 
of  skin  were  more  easily  approximated,  I  joined,  by  passing 
three  delicate  sewing  needles,  as  hare-lip  pins,  through  several 
points  of  the  wound  :  the  intermediate  points  I  drew  nicely  to- 
gether with  plasters ;  I  was  careful  to  use  the  least  possible 
force  ;  to  make  no  strain  by  the  sutures  ;  to  lay  my  compresses 
light  and  soft  in  the  hollows ;  and  to  roll  my  bandage  round  the 
jaws  very  equally,  and  gently,  for  the  teguments  were  most 
alarmingly  thin,  the  slightest  inflammation  would  have  caused 
the  whole  cheek  to  slough,  so  as  to  leave  the  parts  in  a  dreadful, 
irremediable  condition,  with  the  saliva  continually  flowing  over 
the  cheek,  the  speech  imperfect,  probably  unintelligible,  and  the 
patient  would  have  found  no  way  of  being  nourished,  but  by 
pouring  the  food  down   the   throat,   in  place  of  masticating  or 

that  ?"  he  fat  down  inftantly  in  perfect  compofure,  free  from  pain,  unconfeious 
of  the  operation  being  perlormed,  and  expecting  it  :  when  qucftioned  about  the 
fenfation  which  made  him  ftart  up,  he  faid,  he  felt  nothing  but  as  if  he  had  been 
lhot  in  the  head,  followed  by  a  momentary  confufion,  and  a  total  relief  from  pain. 
He  fuid  he  did  not  imagine  the  operation  done,  becaufe  the  firll  operation  had 
been  a  deliberate  diffe&ion  ;  he  felt  now  perfectly  confident  that  he  was  cured, 
and  returned  home  in  two  days,  fince  which  time,  he  has  lived  in  perfect  health,  h 
happily  married,  and  continues  well  at  this  moment. 
Jannary,  1807. 


Lips,  Cheeks  and  Throat.  493 

swallowing  it.  Happily  the  skin  adhered  in  a  few  days,  the 
needles  were  withdrawn,  in  a  fortnight  he  was  cured. 

But  the  slightest  speck  or  spot  of  imperfection  in  such  a 
work  is  followed  by  severe  self-reproach.  I  am  not  sure  that 
I  observed  my  fault  during  the  operation,  but  certainly  after  the 
cure,  I  took  an  alarm,  far  from  groundless.  I  observed  a  small 
glandular-like  knob  towards  the  lower  part  of  the  cheek,  which 
I  ingeniously  warned  him  might  be  the  source  of  future  dis- 
tress, as  the  small  tumour,  indolent  during  his  infancy  and 
vouth,  had  been  suddenly  the  cause  of  this  mischief;  I  took  his 
promise  that  he  should  be  observant  of  it. 

This  error,  so  opposite  to  my  experience  and  conviction,  so 
unlike  my  general  maxims  and  conduct,  I  sorely  repented.  It 
was  at  the  distance  of  three  years  from  the  period  of  this  ope- 
ration, that  I  received  a  succession  of  letters  from  my  patient, 
announcing  the  return  of  the  disease,  and  asking  permission  to 
come  once  more  to  this  country,  to  put  himself  under  my  care. 
The  small  glandular  knob,  which  I  required  him  to  watch,  had 
increased  in  size,  and  the  gums  also  had  begun  again  to  shoot 
out  small  tubercles;  that  the  new  swelling,  and  the  return  of 
this  disease  had  begun  in  this  small  glandular  knot,  no  bigger 
than  a  pea.  I  remember,  only  from  his  conversation,  not  from 
his  letters :  from  the  complexion  of  these,  one  should  rather 
have  concluded,  that  the  new  growth  was  only  in  the  gum,  be- 
ginning in  the  angle  betwixt  the  gum  and  cheek,  and  in  the 
centre  of  the  cheek  ;  a  part  of  the  tumour,  in  the  extirpation 
of  which,  I  surely  had  not  to  accuse  myself  of  any  fault ;  and 
from  the  slightest  and  most  imperceptible  beginnings,  viz.  a 
small  longitudinal  thickening  along  the  scar  of  the  wound,  a 
small  pea  like  hardening  near  the  lower  part  of  that  scar,  and  a 
similar  hardening  betwixt  the  cheek  and  gum  ;  it  grew  with 
such  rapidity,  that  from  week  to  week  its  increase  was  manifest, 
and  in  less  than  two  years,  it  had  attained  fully  its  original 
size  ;  accompanied  with  pains,  more  distinctly  lancinating,  more 
poignant,  and  frequent,  than  in  its  first  stage.  Again  he  travel- 
led from  Tyrone  to  this  city,  and  after  many  perplexities  and 
fears,  submitted  again  to  the  operation.  I,  on  my  part,  had  no 
slight  motives  for  anxiety,  for  now  actually  the  whole  cheek, 
the  skin  excepted,  was  to  be  cut  away  ;  the  buccinator  muscle, 
and  the  living  membrane  of  the  mouth,  were  both  to  be  cut 
out ;  and  I  was  shocked  to  think,  how  possible  it  was,  how  far 
from  improbable,  that  the  whole  cheek,  even  from  the  slightest 
overstraining  of  the  suture,  or  the  slightest  accidental  fever, 
might  gangrene  and  slough,  and  leave  a  horrible  chasm. 

The  tumour  was  almost  as  large  as  at  first :  the  great  glan- 
dular-looking substance,  rounder  and  more  uniform;  the  livid 


494  On  Tumours  of  the  Gums, 

part  of  the  surface  of  greater  extent,  and  a  stage  nearer  ulcera- 
tion, and  the  scar  of  the  former  operation  binding  the  tumour 
firmly  along  its  whole  length  ;  and,  except  in  the  very  apex  of 
the  most  bulky  and  prominent  part,  where  indeed  it  was  more 
elastic,  the  whole  was  of  a  stony  hardness,  accompanied  with 
perpetual  pain,  by  which,  together  with  his  fatigues,  and  fears, 
in  this  wearisome  journey,  he  was  greatly  cast  down.  It  now 
also  approached  so  close  to  the  angle  of  the  mouth,  that  I  saw 
no  way  of  extirpating  the  tumour,  and  leaving  more  than  a 
quarter  of  an  inch,  hardly  so  much,  entire,  betwixt  the  gap 
made  by  the  extirpation  of  the  tumour  and  the  mouth. 

I  proceeded  to  make  first,  a  long  incision,  bending  a  little,  so 
as  to  include  all  the  tumour  that  was  below  the  cicatrix,  and 
which,  in  bending  round  the  tumour  almost  touched  the  angle 
of  the  mouth  next,  a  similar  incision  bending  upwards,  in  such 
a  direction,  as  to  include  the  scar  of  the  former  operation,  the 
puckered  and  adhering  skin,  and  a  part  of  the  tumour,  all  that 
part  to  which  the  skin  inseparably  adhered.  Those  two  inci- 
sions included  that  part  of  the  adhering  skin,  which  required  to 
be  extirpated,  in  the  same  manner,  that  we  usually  include 
within  an  oval  incision,  the  nipple  of  a  much  indurated  mamma. 
Thirdly,  I  made  a  tranverse  incision,  from  the  temple,  i.  e. 
from  the  tip  of  the  ear  over  the  zygoma,  directly  across  the 
face,  which  meeting  the  first  oval  incision  made  two  flaps.  The 
tumour  I  found  now  more  regular  in  its  form  than  I  expected, 
sacculated,  and  very  dark  and  bloody  ;  I,  after  raising  the  an- 
gles of  the  skin  from  the  cheek  and  face,  and  saving  all  of  the 
skin  that  I  could  save,  dissected  all  round  the  tumour,  and  re- 
served those  parts  of  the  dissection  for  the  last,  in  which  I  had 
to  divide  arteries.  I  then  dissected  out  the  tumour  from  the 
angle  of  the  mouth,  and  tied  the  labial  artery ;  then  dissecting 
down  through  the  lowest  part  of  the  incision,  into  the  cavity  of 
the  mouth,  I  tied  there  the  trunk  of  the  fascial  artery  ;  and  finally 
dissecting  out  the  tumour  from  under  the  cheek-bone, and  tearing 
it  from  the  zygoma,  a  most  difficult  and  painful  dissection,  I 
tied  a  large  branch  from  the  transversalis  faciei.  The  veins 
spouted  out  blood  profusely  when  cut,  but  shrunk  instantly : 
the  arteries  thus  successively  tied  bled  none.  I  never  indeed 
performed  so  unseemly,  and  at  the  same  time  so  bloodless  an 
operation. 

Now  observe,  that  in  all  these  points,  and  to  the  full  extent 
of  the  tumour,  I  was  obliged  to  go  fairly  through  the  cheek, 
and  cut  every  thing  completely  away,  for  it  was  all  tumour. 
The  tumour  looked  formidable  when  it  presented  itself,  in  time 
of  dissection,  high  above  the  separated  flaps  of  the  skin,  and 
the  chasm  was  horrible  when  it  was  cut  away  ;  the  flaps  consist 


Lips,  Cheeks,  and  Throat.  495 

ing  of  skin  only,  were  so  thin,  that  I  was  in  despair  when  I 
laid  them  together ;  I  solemnly  declare,  that  nothing  ever  asto- 
nished me  more,  than  the  speedy  cure,  which  was  such  as  must 
give  me  courage  on  all  occasions  that  may  in  future  occur. 
First,  my  assistant,  Mr.  Allan,  brought  the  edges  nicely  to- 
gether, and  passing  a  needle  through  the  three  points  of  the  in- 
cisions, I  brought  them  altogether  in  one  star-like  centre,  ex- 
actly in  the  middle  of  the  cheek.  But  one  ligature,  though  it 
approaches  two  points  nicely,  cannot  go  under  a  third,  and  bring 
it  into  contact  with  the  other  two,  without  turning  over  and  pass- 
ing from  within  outwards ;  in  consequence  of  this  awkward- 
ness, for  which  I  was  provoked  with  myself,  I  had  almost 
balked  the  great  purpose  of  re-union,  and  that  too  at  the  very 
centre  of  all  the  sutures,  and  therefore  endangering  each  of  them, 
and  of  course  in  the  centre  of  the  cheek,  so  that  the  whole 
cheek  was  endangered  ;  but  fortunately  the  suppuration,  in  this 
central  point,  was  very  slight :  yet,  however  slight,  it  grieved 
me,  as  it  plainly  proceeded  from  my  awkwardness.  I  then 
took  the  most  delicate  sewing  needles,  mounted  on  small  wooden 
shafts,  like  pencil  sticks,  and  passing  two  needles  from  side  to 
side  across  each  long  incision,  I  brought  the  sidts  of  the  three 
radiated  incisions,  into  the  nicest  contact  imaginable,  careful  al- 
ways not  to  twist  my  threads  round  the  needles  too  tight ;  and 
I  passed  one  very  delicate  needle  close  to  the  angle  of  the 
mouth,  to  secure  that  point. 

This  I  do  on  all  occasions,  and  always  very  deliberately,  and 
at  some  distance  of  time  after  the  operation,  and  when  there  is 
no  longer  any  bleeding  to  discompose  me  ;  and  every  thing 
sponged,  clean,  nice,  and  dry,  I  take  narrow  strips  of  linen,  and 
dipping  them  in  warm  glue,  lay  them  across  the  incisions,  and 
these  being  well  dried,  and  hardened,  and  the  needles  kept  clear 
of  the  glue,  I  can,  without  risk,  on  the  end  of  the  second  day, 
or  on  the  third,  before  there  can  be  the  slightest  risk  of  suppu- 
ration, slip  out  my  needles  one  by  one. 

So  I  did  in  this  case  ;  the  less  necessary  needles  I  withdrew 
on  the  second  day ;  those  on  which  more  depended,  I  left  till 
the  third  and  fourth  days ;  and  the  needle  nearest  the  centre  I 
left  longest.  I  draw  each  needle  with  nice  forceps,  turning  it 
first  a  little  vertically,  that  there  may  be  no  tugging.  I  often 
pass  a  thread  into  the  eve  of  the  needle,  that  I  may  pull  quite 
vertically,  and  often  pass  a  flat  stick  betwixt  the  ends  of  this 
thread,  and,  twisting  the  ends  round  the  stick,  turn  the  needle 
vertically,  and  so  loosen  it  with  so  true  a  motion,  that  there  is 
not  the  slightest  sensible  violence,  nor  the  smallest  drop  of 
blood  ;  and,  before  I  attempt  to  move  a  needle,  I  take  a  hair 
pencil,  and,  by  washing  and  cleaning  the  point,  and  oiling  it, 


496  On  Tumours  of  the  Gum&, 

prepare  it  for  passing  easily.  This  method  I  have  long  used  in 
all  delicate  sutures,  especially  in  extirpating  small  tumours  of 
the  face  and  jaws,  and  in  hare-lips.  It  was  in  this  manner  I 
re-united,  a  second  time  (the  operation  having  been  very  mal- 
adroitly  performed  upon  him  when  a  boy,)  the  hare-lip  of  Mr. 
Whirter,  surgeon,  of  Newcastle,  with  a  scar  hardly  visible,  and 
with  an  evenness  of  lip  which  enables  him  to  blow  the  flute  very 
delicately.  He  was  conscious  of  the  necessity  of  this  second 
operation,  and  gratified  with  the  success  of  it. 

I  have  another  remark  to  make  to  you,  that,  though  a  needle 
is  withdrawn,  its  twisted  suture  remains  upon  the  surface,  cak- 
ed with  blood,  and  is  a  security  to  the  wound ;  and  always,  up- 
on withdrawing  each  needle,  I  heat  the  glue-pot  again,  and 
dipping  a  hair-pencil  in  it,  I  wash  the  remaining  ligature,  or 
twisted  thread  with  glue,  so  that  the  needles  being  removed  on 
the  second,  third,  and  fourth  days,  there  are  substituted  to  them 
various  strips  of  fine  linen,  with  glue,  and  the  pencil  being 
carried  over  all  parts  of  the  incision,  the  whole  is  held  firmly,  yet 
gently  together,  by  a  cake  or  plaster  of  glue,  which  need  not 
once  be  troubled  till  you  find  it  safe  to  wash  off  the  whole  at 
once. 

This,  compared  with  the  common  adhesive  plaster  of  wax. 
is  a  nice  and  cleanly  manner  of  performing  those  operations  in 
which  so  much  depends  upon  delicacy,  and  the  nice  and  curious 
contact  of  all  the  edges  ;  for  any  one  point  left  open  endangers 
the  whole  line  of  suture  ;  and  this  method  had,  in  the  present 
instance,  such  perfect  success,  that,  in  ten  days  Mr.  Taylor  be- 
gan his  journey  to  Ireland  perfectly  cured,  and  with  less  mark 
of  incision,  and  a  more  perfect  evenness  of  cheek  than  at  first.* 
In  an  hospital,  an  unhealthy  season,  or  an  unsound  constitution, 
the  whole  of  such  incisions  must  have  sloughed  off,  a  dreadful 
and  an  irremediable  calamity!  but  in  this  healthy  and  vigorous 
young  man,  the  parts  united  most  happily. 

In  operating  on  this  tumour,  I  was  surprised  to  find  a  very 
singular  connection  betwixt  the  veins  and  the  central  and  more 
conspicuous  tubercles,  which  were  indeed  firm  but  elastic  sacs, 
of  pure  and  coagulated  blood,  inclosed  in  very  thick  and  solid 
walls ;  and,  upon  dissecting  the  tumour  after  it  was  laid  upon 
the  table,  the  great  tubercle  being  cut  open,  and  the  hard  and 
clotted  blood  turned  out,  it  was  manifest  and  visible,  distinctly 

•  The  part  was  not  covered  with  lint  or  comprefs  for  fear  of  dilordering  the 
needles,  or  concealing  any  accidental  inflammation,  but  to  prevent  any  ill  confe- 
rences from  the  extreme  hollownefs  of  cheek,  a  nice  fitted  plumper,  or  comprefs 
of  lolt  rolled  lint,  was  introduced  hi  to  the  mouth,  and  the  jaws  bandaged  to  pre- 
vent motion  during  flecp,  and  he  was  hardly  permitted  to  lie  down  ir.  bed  foi  . 
of  fome  mifchance. 


Lips,  Cheeks,  and  Throat.  497 

visible,  that  these  cellular  cavities  had  communications  with  the 
greater  veins. 

Many  distressing,  and  some  fortunate  cases  of  this  nature 
have  been  under  my  care  ;  tumours  of  a  less  malignant  nature, 
and  easily  extirpated,  present  themselves  daily,  and  excite  no 
perturbation  ;  but  I  would  endeavour,  by  relating  less  favour- 
able or  fortunate  cases,  to  enure  you  to  difficulties,  and  disap- 
pointments. 

"  Mr.  S ,  a  venerable  old  man  of  60  years  of  age,  re- 
markably strong,  active,  and  athletic,  for  his  time  of  life,  had 
been  long  subject  to  a  very  dangerous  swelling  of  the  parotid 
gland,  which  now  manifestly  declined  to  a  state  of  cancer. — 
The  tumour  began  early  in  life,  and  was  extirpated  twenty  years 
ago  by  Mr.  Dunlop,  a  celebrated  surgeon  in  Glasgow  :  but  a 
gland  in  which  the  trunk  of  the  carotid  artery  is  so  entirely  im- 
bedded, can  never  be  entirely  extirpated,  thence  it  has  grown 
again  slowly.      Mr.    Dunlop  declining  himself  to   perform  the 

operation,  and  yet   desirous  that  Mr.  S should   have  every 

possible  chance  for  life,  has  requested  me  to  receive  him  under 
my  care. 

11  The  tumour  is  divided  in  the  middle  by  the  scar  of  the  for- 
mer operation  ;  along  that  line  it  is  irregularly  straightened  and 
bound  down  ;  it  rises  on  each  side  of  the  scar,  in  knobs  or  api- 
ces of  a  stony  hardness,  reddened  of  late  on  the  surface,  with 
a  coarse  granulated  and  adhering  skin.  The  whole  surface  of 
the  tumour  is  of  a  dusky  red,  and  its  extent  very  great,  for  it 
covers  all  the  flat  part  of  the  cheek  ;  a  flattened  part  rises  over 
the  zygoma,  towards  the  temple,  to  which  it  adheres  very  firm- 
ly ;  one  glandular  and  almost  separate  lump,  lies  far  forwards 
upon  the  cheek,  and  seems  to  me  a  tumour  of  the  socia  paroti- 
dis,  while  the  rest  is  a  tumour  assuredly  of  the  parotid  itself. — 
The  tumour  is  so  large  as  to  be  flat  though  bulkv  ;  the  most 
salient  point  is  that  which  lies  immediately  before  the  ear,  the 
lap  of  which  is  turned  back  by  it  ;  another  branch,  I  may  call  it, 
of  the  tumour,  lies  under  the  lap  of  the  ear,  and  presses  it  up- 
wards ;  the  chief  mass  of  the  tumour  lies  upon  the  cheek,  but 
a  very  bulky  part  lies  deeply  imbedded  behind  the  angle  of  the 
lower  jaw-bone  ;  its  appearance  was  unpropitious,  for  it  was  of 
a  deep  red  colour,  sensibly  inflamed,  the  inflammation  increas- 
ing every  day,  with  a  deep  and  stunning  pain,  while  all  the  basis 
of  the  tumour  was  as  hard  as  stone. 

"  Nothing  can  be  more  unpropitious  than  the  state  of  this 
gland  ;  first,  it  is  a  disease  returning  long  after  its  growth  had 
been  interrupted  by  amputation  :  secondly,  it  is  very  firm,  of  a 
stony  hardness,  very  irregular  and  knobby  ;  that  part  which 
lies  out  upon  the  cheek  is   bound  down  firm,  and   flat,  bv   the 

3  R 


498  On  Tumours  of  the  Gums, 

fascia,  or  tendinous  membrane  that  descends  from  the  zygoma, 
and  by  the  platysma  myoides  muscle:  thirdly,  it  is  growing 
sensibly  and  rapidlv,  and  its  surface  has  begun  to  take  a  deep 
and  livid  colour,  while  very  poignant  and  torturing  pains  shoot 
through  the  tumour,  prevent  his  slec-p,  and  distract  him  while 
awake.  This  sihirrus  has  every  character  of  approaching  can- 
cer, it  is  most  likely  too  late  to  attempt  the  operation,  yet  what 
would  not  one  do  or  suffer  to  preserve  lite  ?  The  operation  too 
is  full  of  danger ;  this  gland  cannot  be  extirpated  but  by  deep 
incisions,  and  a  very  severe  and  slow  dissection  ;  at  the  best,  it 
cannot  be  separated  from  the  angle  of  the  jaw,  without  cutting 
the  portio  dura  of  the  auditory  nerve,  and  paral\  zing  the  cheek ; 
nor  without  dividing  the  temporal,  facial,  and  other  arteries  : 
perhaps  it  may  not  be  possible  to  extirpate  it  totally,  for  fear  of 
wounding  the  very  trunk  of  the  carotid  artery,  and  that  opera- 
tion which  is  begun  with  the  knife,  it  may  be  necessary  to 
finish  less  perfectly  with  the  ligature.  This  is  the  first  time  I 
have  been  obliged  to  think  of  such  a  resource  :  the  latter  part  of 
the  operation  must  be  performed  by  poising  out  the  gland  from 
the  deep  hollow  under  the  zygoma,  and  behind  the.  angle  of  the 
jaw,  and  then  it  may  be  necessary  to  strangle  with  the  ligature, 
what  assuredly  we  dare  not  amputate  with  the  knife. 

"  I  came  to  this  decided  conclusion  in  my  own  mind,  that, 
though  a  case  the  most  unpromising  I  had  ever  witnessed,  it 
was  my  duty,  in  compliance  with  Mr.  Dunlop's  and  his  pa- 
tient's wishes,  and  with  Dr.  Monro's  advice,  to  perform  the 
operation,  difficult  as  it  seemed,  and  it  was  plainly  such  as  ad- 
mitted of  no  previous  plan,  but  required  that  I  should  be  guid- 
ed by  circumstances,  and  my  past  experience,  for  I  had  often 
[partially']  extirpated  the  diseased  parotid. 

M  I  can  hardly  enter  too  much  into  the  detail  of  such  an  opera- 
tion, seeing  especially  that  it  had  an  unfavourable  issue  ;  I  en- 
tered upon  it  with  more  than  usual  composure,  with  more  than 
I  thought  natural  to  the  occasion,  but,  I  believe,  it  was  the 
very  difficulty  of  the  case  that  reconciled  me  to  my  task,  for  I 
was  conscious,  in  such  difficult  circumstances,  I  was  entitled  to 
stop,  that  it  was  my  duty  to  stop,  the  moment  I  approached 
any  dangerous  point,  that  I  was  no  way  responsible  for  extirpa- 
ting the  whole  tumour,  nor  for  doing  all  with  the  knife.  The 
peculiar  complexion  of  the  tumour,  for  it  was  now  inflamed  al- 
most to  ulceration,  and  accompanied  with  lancinating  pains,  was 
unfavourable  to  our  hopes  ;  its  growth,  after  being  once  extir- 
pated, confirmed  the  suspicion  of  its  being  of  a  cancerous  na- 
ture ;  and  the  parotid  has  the  temporal  and  maxillary  arteries 
imbedded  in  it,  while  the  portio  dura,  or  middle  nerve  of  the 
face,  that  great  nerve  which  runs  across  the  cheek,  and  goes  to 


Lips,  Cheeks,  arid  Throat,  499 

all  the  side  of  the  face,  passing  through  it  in  many  branches, 
so  that  it  absolutely  cannot  be  cut  away  from  its  root,  which 
sinks  deep  behind  the  branch  of  the  lower  jaw-bone,  without 
cutting  the  carotid  artery  ;  and  it  cannot  be  torn  away,  the  firm 
nerve  being  entwined  with  its  substance ;  even  the  casting  a  lig- 
ature about  the  root  of  the  gland  is  accompanied  with  excrucia- 
ting and  maddening  pain,  the  nature  of  which  may  be  imagined 
from  the  agony  which  a  tooth-ach  or  a  rheumatic  affection  of 
the  temple  causes.  The  act  of  tying  a  nerve,  I  am  conscious, 
products  a  kind  of  i:  jurv,  accompanied  with  terrible  inflamma- 
tion :  this  injurs  is  permanent,  and  the  inflammation  becomes 
habitual.  It  often  happens,  for  example,  that  the  nerves  of  an 
amputated  stump  are  so  engaged  in  the  cicatrix,  that  their  ex- 
tremities being  superficial,  and  covered  only  with  a  delicate 
and  thin  cicatrix,  the  slightest  accident  irritates  and  inflames 
them  ;  and  I  hive  seen  a  stump  exposed  by  this  to  paroxysms 
of  inflammation,  in  which  the  stump  swelled  to  the  size  almost 
of  the  pati<  nt's  bodv,  attended  with  fever,  and  such  convulsive 
starti ngs  of  the  stump  as  usually  occur  immediately  after  am- 
putation. The  cutting  of  the  portio  dura,  or  nerve  ot  the  face, 
occasions  the  most  excruciating  pain,  as  I  have  already  explain- 
ed in  the  case  of  Cap.  G ,(vid.  foot  note  to  page  490)  and 

I  have  reason  to  believe,  that  the  pain  proceeding  from  the 
truncated  extremity  ot  this  nerve  being  unavoidably  engaged  in 
the  cicatrix  after  an  operation  such  as  this,  causes  the  return  of 
the  swelling,  revives  the  disease  in  whatever  remains  of  the 
gland,  and  is  the  cause  of  its  cancerous  nature. 

"  Mv  incisions  were  made  in  a  tripod-like  form  ;  not  straight 
but  bending,  so  as  by  thtir  prolongation  over  the  cheek,  ear, 
and  temple,  to  make  a  triangle,  in  direct  lines  with  three  corn- 
ers, which  being  dissected  away,  exposed  the  convex  part  of 
the  tumour.  By  giving  these  three  incisions  a  circular  form  in 
the  centre,  I  left  the  adhering  part  of  the  skin,  attached  to  the 
most  diseased  part  of  the  gland,  and  this  centre  of  knobulur  and 
stony  glandular  substance,  with  thickened  and  adhering  skin, 
connected  firmly  by  the  scar  of  the  former  operation,  I  left 
untouched,  and  cut  up  three  flaps  of  thin  and  sound  skin. 

"  After  dissecting  back  the  flaps  exposing  the  surface  of 
the  tumour,  I  dissected  away  that  part  of  the  tumour  which 
approached  the  mouth,  and  lay  upon  the  masseter  muscle,  with 
which  it  was  so  connected  that  I  chose  to  cut  away  large  pieces 
of  the  muscle,  hardened  and  identified  with  the  tumour,  leav- 
ing the  jaw-bone  bare  near  its  angle,  rather  than  leave  any  part 
of  the  disease.  Next,  I  turned  the  tumour  down  from  the 
ear  ;  but  do  not  imagine  this  was  accomplished  easily,  as  in 
ordinary  tumours  bedded  in  loose  cellular  substance  ;  this  tu- 


oOO  On  Tumours  of  the  Gums, 

mour  was  so  firmly  embraced  by  the  fascia,  and  adhered  so  firm- 
ly to  the  zygoma,  to  the  thick  fascia  which  descends  from  it, 
and  to  the  tendinous  parts  of  the  temporal  muscle,  that  I  was 
cutting  through  a  firm,  mixed,  cartilaginous  substance,  and 
could  not  distinguish  where  I  had  got  through  the  gland,  or  its 
adhesions,  but  by  distinguishing  that  I  was  cutting  muscular 
flesh,  or  encountering  a  naked  bone.  The  third  part  of  the 
dissection  was  at  once  cruel  and  full  of  danger  ;  it  was  the  dis- 
secting away  the  tumour  from  the  cartilaginous  tube  of  the  ear, 
which  was  yet  done  so  effectually,  as  to  detach  the  tumour  from 
the  whole  length  of  that  tube,  down  to' the  temporal  bone  ;  but 
there,  a  big  and  firm  root  seemed  so  fixed,  that  I  durst  go  no 
further  with  the  knife  ;  I  had  dissected  the  tumour  backwards 
from  the  cheek,  and  upwards  from  behind  the  jaw-bone,  and 
insulated  it  up  to  that  point  where  the  temporal  artery  transfixes 
the  gland  just  before  the  ear  ;  there,  it  will  be  recollected,  the 
great  internal  maxillary  artery  divides  from  the  temporal  arte- 
ries ;  I  could  go  no  further,  the  next  stroke  of  the  knife  would, 
in  severing  the  gland  from  its  root,  have  cut  the  common  root 
of  the  maxillary  and  temporal  arteries  ;  would,  in  short,  have 
truncated  the  carotid  artery  ;  what  remained  of  the  operation 
could  therefore  be  done  only  by  ligature. 

u  In  this  d:ssection  I  experienced  all  the  difficulties  peculiar 
to  a  second  operation  ;  for  a  gland  which  grows  again  after  be- 
ing cut,  is  so  bound  down  to  every  subjacent  part,  by  the  scar 
of  the  skin,  and  by  new  and  strong  adhesions,  that  its  connec- 
tions are  of  an  unusual  and  cartilaginous  firmness  :  and  I  had, 
in  this  case  to  encounter  the  additional  danger  of  a  tumour  far 
advanced  in  its  progress  towards  the  last  stage  of  schirrus,  and 
ready  to  degenerate  into  cancer  ;  and  it  appears  to  me  that  that 
unfavourable  change  which  is  marked  by  shooting  pains,  consists 
in  inflammation,  is  accompanied  with  adhesions,  or,  to  speak 
more  truly,  with  a  consolidation  of  the  diseased  gland,  with 
surrounding  bones  and  muscles,  just  as  the  schirrous  breast  is 
united  solidly  and  in  substance,  with  the  pectoral  muscles,  and 
the  ribs  :  in  the  present  case,  the  fascia,  descending  from  the 
zygoma  over  the  surface  of  the  tumour,  was  identified  with  its 
substance,  and,  when  cut,  was  like  a  cartilaginous  ligament, 
hard,  and  thick.  The  dissection  of  the  part  of  the  tumour  which 
lay  over  the  jaw,  and  masseter  muscle,  was  equally  rude,  and 
imperfect;  for  the  tumour  was  equally  identified  with  the  sub- 
stance of  this  muscle,  which  was,  in  its  own  substance,  of  a 
gristly  hardness.  The  tumour,  in  short,  adhered  to  the  fascia 
of  the  temple,  to  the  zygoma,  to  the  masseter,  to  the  jaw-bone, 
and  to  the  cartilaginous  tube  of  the  ear;  from  all  of  which,  it 
was  more  or  less  rudely  or  delicately  dissected  ;  but  with  such.- 


Lips,  Cheeks,  and  Throat.  501 

excruciating  pain  that  Mr.  S ,  though  a  man  of  the  most 

perfect  composure,  courage,  and  constancy,  grew  deadly  pale, 
hiccuped,  fainted,  would  have  fallen  from  the  chair,  had  he  not 
been  supported,  and  that  so  early  in  the  operation,  that  even  his 
neckcloth  was  not  yet  stained,  at  least  not  wet,  with  blood. 

"  We  were  obliged  to  lay  him  down,  to  lave  cold  water  on 
his  face,  to  suspend  the  dissection  for  a  whole  quarter  of  an 
hour  ;  this  was  in  the  beginning  of  the  operation,  which  lasted 
ten  minutes  after  it  was  resumed. 

44  The  first  artery  which  sprung  was  the  transversalis  faciei, 
but  it  was  too  small  to  be  heeded,  and  it  was  to  be  cut  again, 
wherefore  I  disregarded  it,  and  it  shrunk :  the  next  artery,  in 
dissecting  the  lower  part  of  the  tumour,  was  the  labial  or  facial, 
where  it  turns  round  the  angle  of  the  jaw  ;  in  this,  as  in  all 
other  dissections  of  the  like  nature,,  it  stood  out  from  its  cellular 
substance  so  insulated,  to  the  extent  of  half  an  inch,  that  I  found 
it  easv,  without  the  needle  or  tenaculum,  to  casta  ligature  round 
it,  by  laving  the  loop  of  the  ligature  over  its  mouth,  and  draw- 
ing it :  the  third  artery  was  the  great  temporal  artery  ;  the  man- 
ner in  which  it  presented  was  not  pleasant,  for,  first,  in  dissect- 
ing downwards  that  part  of  the  tumour  which  covered  the  z\  go- 
ma,  the  artery  was  necessarily  opened  ;  but  knowing  that  I 
had  not  approached  any  dangerous  point,  I  clapped  the  point  of 
my  left  fore-finger  on  the  mouth  of  the  artery,  while  grasping 
the  body  of  the  tumour  in  the  hand,  I  continued  to  dissect  it 
downwards  from  the  temple,  and  to  dig  it  away  from  the  carti- 
laginous tube  of  the  ear;  then,  lifting  the  point  of  my  fore-fin- 
ger, the  mouth  of  the  artery  appeared  in  the  very  centre  of  the 
tumour,  throwing  out  its  blood,  and  was  tied.  By  dissecting 
the  gland  down  from  the  zygoma,  and  from  behind  the  angle 
of  the  jaw,  I  had  almost  touched  the  point  where  the  carotid 
forks  into  the  internal  maxillary  and  temporal  arteries  ;  to  have 
gone  further,  would  have  been  rash  and  unpardonable  ;  the 
next -stroke  of  the  knife  would  have  truncated  the  carotid  arte- 
ry and  left  no  possible  chance  of  saving  the  patient,  but  instant 
compression  of  the  artery  at  that  point  with  the  thumb,  and  a 
desperate  dive  with  the  crooked  needle  at  that  part  behind  the 
angle  of  the  jaw,  where  the  trunk  forks  into  the  external  and  in- 
ternal carotid  arteries. 

44  I  wrought  so  successfully  with  my  fingers,  as  to  insulate 
the  gland  all  but  a  trivial  root;  I  then  pushed  the  flat  handle  of 
the  scalpel  round  and  round,  so  as  to  lessen  that  root  still  more  : 
I  next  with  the  fingers  alone  passed  a  big  and  thick  ligature 
round  the  root  of  the  tumour,  and  tied  it  in  a  general  way,  and 
by  the  hold  of  this  ligature  was  enabled  to  turn  the  tumour 
round  like  a  button  upon  its  stalk,  and  by   compressing  it,  was 


502  On  Tumours  of  the  Gums, 

enabled  to  feel  more  distinctly  to  the  root  of  this  slender  neck. 
I  believed,  but  I  was  mistaken,  that  I  could  drive  the  eyed  end 
of  my  needle  through  this  ;  it  was  of  far  too  firm  a  substance 
for  any  such  attempt ;  but  resolved  any  way  to  get  at  its  root 
I  turned  at  last  the  point  of  the  needle  to  this  pedicle,  struck  it 
through  behind  the  general  ligature,  and  having  thus  carried  a 
very  thick  waxed  ligature  through  the  root,  I  cut  the  ligature  at 
the  eye  of  the  needle,  tied  two  of  the  ends  round  one  side  of 
the  tumour,  the  two  others  round  the  other  side  of  the  tumour, 
then  crossing  them,  and  bringing  the  respective  ends  round  the 
opposite  sides  of  the  tumour,  I  titd  them  again  ;  and  as  this 
was  the  point  necessarily  including  the  portio  dura,  or  great  nerve 
of  the  side  of  the  face,  the  drawing  of  the  ligatures  proved  the 
most  cruel  part  of  the  operation,  was  accompanied  with  an 
outcry  of  intolerable  suffering  ;  the  cheek  fell  paralytic,  and  be- 
came instantly  oblique,  and  1  was  impressed  also  with  the  con- 
viction, fiat  I  had  so  pulled  out  the  gland  by  the  help  of  the 
general  ligature  from  its  deepest  seat,  betwixt  the  jaw  and  tem- 
poral bone,  that  I  had,  in  tying  the  root  of  the  schirrous  gland 
and  the  portio  dura,  tied  also  the  carotid." 

"  The  gland  was  cut  off,  and  only  a  button  left  with  those  lig- 
atures about  it  ;  the  whole  operation  was  bloodless  :  at  the  first 
dressing,  at  the  distance  of  four  days,  the  whole  surface  was 
found  in  a  state  of  kindly  suppuration,  but  the  ligatures,  espe- 
cially that  which  encircled  the  lower  part  of  the  tumour,  needed 
to  be  drawn  firm,  which  occasioned  once  more  excruciating 
pain,  which  continued  through  the  whole  night,  during  which 
our  patient  was  feverish  and  restless.  On  the  second  dressing, 
at  the  distance  of  seven  days  from  the  operation,  I  found  the 
gland,  or  the  remains  of  it,  not  killed  by  the  ligature,  but  adhering 
round  all  its  edges,  to  the  surrounding  parts  ;  and  especially  I 
found  it  adhering  firmly  to  the  flap  of  the  ear.  I  disengaged  the 
adhesions  with  the  probe,  and  examined  the  ligatures  and  found 
them  loose  ;  but  having  fixed  them  with  running  knots  at  the  last 
dressing,  I  now  finding  it  impossible  to  draw  them  tighter,  took 
another  method,viz.  passing  the  ends  of  the  upper  ligature  through 
the  eye  of  a  large  crooked  needle,  and  carrying  it,  eye  foremost; 
round  the  gland,  I  carried  the  same  ligature  a  second  time  round 
the  neck  of  the  tumour,  and  tied  and  drew  it  again  with  consider- 
able pain.  The  button-like  head  and  neck  were  now  so  hard  and 
brittle,  that  I  might  safely  have  snipped  them  across,  but  I  thought 
it  best,  since  the  ligature  still  occasioned  pain,  to  leave  it  to  kill 
the  part  completely.  At  a  third  dressing  I  found  still  the  gland 
not  killed,  but  adhering  to  the  ear,  and  bleeding  when  touched, 
so  that  Dr.  Monro  could  not  be  persuaded  that  the  ligature 
actuallv  surrounded  the   tumour.     I  drew  the  ligature  now  a 


Lips,  Cheeks,  end  Throat.  503 

fourth  time  with  great  pain  ;  I  waited  for  its  sloughing,  as  this 
root  of  the  gland  seemed  to  delay  the   cure,  which  was  other- 
wise far  advanced  ,  but  at  the  next  dressing  I  found  the  tumour 
hard,  brittle,  entirely  blackened,  and  turning  in  every  direction 
upon  its  narrow  neck,  which  I   twisted    off  with  a   very  slight 
twitch,  merely  by  turning  it  round  and  round.     The  surfaces 
suppurated  fairly,  and  granulated  ;  and  the  cheek  healed  even- 
ly and  well:    but  the   pains  never  entirely  ceased  ;  our  patient 
had  rheumatic  feelings  in  all  that  side  of  the  head,  always  re- 
ferable to  the  diseased  part:  they  were  increased  in  moist  wea- 
ther, or  when  the  east  wind  blew.       He  retired  to  a  delightful 
climate  near  the  mouth  of  the  Clyde,  and  while  there  the  thick- 
ening of  the  parts  daily  lessened,  and  I  flattered  myself  he  would 
entirely   recover;  but  after  receiving  from   our  patient  a  suc- 
cession of  very  afflicting  letters,  he  returned  to  me  in  the  month 
of  January,  in  a  very  calamitous  situation,  with  the  tumour  al- 
mostas  big  as  in  the  month  of  July,  when  the  operation  was  per- 
formed, and  having  all  the  aspect  of  a  part  ready  to  burst  out  into 
cancer.  The  surface  and  the  cicatrix,  and  all  that  belonged  to  the 
skin,  seemed  to  be  particularly  diseased,  and  prone  to  ulcera- 
tion.    Three  points  stood  particularly  prominent  like  knuckles, 
from  the  centre  of  the  sore  :  these  were  the  three  corner  points 
of  the  skin  formed  by  the  triangular  incision  ;  they  were  of  a 
dull  red  colour,  extremely  painful,  with  an  indistinct  sense   of 
fluctuation,  or  rather  of  boggyness,  (soft  and  hard  mixed,)  and 
resembled  in  short  the  livid  skin  of  a  schirrous  breast,  when  the 
operation  having  been  unsuccessful,  the  part  is  about  to  burst 
into  open  cancer.      The  pain  which  had  for  some  months  been 
moderate  and  tempered  with  intermissions,  was  now  unremit- 
ting, extremely  severe,  shot  across  the  cheek  during  the  day 
with  stunning  violence,  and  at  night  was  so  fierce  and  intolera- 
ble, like  the  burning  of  live  coals,  that  he  wished  for  ice  to  apply 
it  to  to  the  side  of  his  head  ;  and  even  with4arge  doses  of  opium, 
which  he  had  learned  to  use,  he  passed  much  of  the  night  with- 
out closing  his  eyes.     With    Dr.  Monro's   consent,  the  usual, 
the  hopeless,  prescriptions  of  hyosciamus  and  mercury  were  giv- 
en him,  and   he   returned  to  the  care  of  his  surgeon  at  home, 
.  whose  letters  announced  to  us  only  a  succession    of  sufferings 
daily  more  and  more,  and  were  terminating  at  last  in  a  fatal 
cancer  :   he  survived  but  a  few  months." 

Those  more  ordinary  operations  on  tumours  rolling  under 
the  skin,  insulated,  easily  extirpated,  and  which  we  know  it  to 
be  our  duty  to  dissect  out,  as  a  measure  of  precaution,  I  need 
not  describe  to  you  ;  but  those  in  which  there  is  any  thing  either 
singular  in  the  place  of  the  tumour,  or  critical  in  the  dissection 
required,  I  hold  it  my  duty  to  represent ;  and  I  am  permitted 


504  On  Tumours  of  the  Gums, 

by  Mr.  Dunlop,  surgeon  in  Glasgow,  to  explain  to  you  some 
things  very  singular  in  the  operation  which  he  found  it  prudent 
to  submit  to  in  bis  own  person. 

Mr.  Dunlop,  surgeon,  after  deliberate  and  frequent  consulta- 
tion with  his  father,  resolved  to  rid  himself  of  a  continual  anxi- 
ety in  regard  to  a  glandular  swelling,  deep  seated,  lying  imme- 
diately under  the  lobe  of  the  ear,  and  which  had  been  increasing, 
though  slowly,  lor  five  years.  No  well  instructed  surgeon 
could  be  indifferent  to  the  consequences  of  such  a  tumour  in 
his  own  person.  Had  the  gland  been  a  mere  scrophulous 
swelling,  he  might  have  waited  the  event  patiently,  of  it  sup- 
purating, shrinking,  or  remaining  stationary  ;  but  a  ^land,  hard 
as  a  stone,  gradually  increasing  in  size,  deep  seated,  extending 
its  adhesions,  and  connecting  itself  with  the  carotid  artery  and 
portio  dura,  was  not  to  be  long  disregarded.  Much  as  I  have 
been  in  the  habit  of  comparing  external  with  the  corresponding 
internal  parts,  and  planning  operations,  there  were  many  things 
in  this  dissection  altogether  unexpected,  and  for  which  I  was  in 
no  shape  prepared.  I  felt  (more  than  even  in  those  cases  in 
which  I  had  been  correct  in  my  conjectures,)  the  necessity  of 
thinking  long  before  lifting  the  knife :  I  was  sensible  of  some- 
thing very  uncommon  and  anomalous  in  this  tumour,  for  though 
it  did  not  seem  to  adhere,  it  lay  very  deep,  though  moveable, 
its  form  could  not  be  distinguished,  though  extremely  hard  and 
globular,  it  seemed  to  be  covered  with  coats  of  an  extraordinary 
and  unaccountable  thickness  ;  and,  if  I  can  pretend  to  remember 
any  conjecture  I  made,  it  was  a  very  mistaken  one,  viz.  that 
the  fascia,  fat,  and  cellular  substance  had  thickened  to  a  singular 
degree  over  it.  But  Mr.  Dunlop,  passionately  desirous  of  be- 
ing rid  of  the  tumour,  required  that  I  should  perform  the  opera- 
tion without  delay. 

The  usual  apparatus,  of  knives  and  needles,  a  fork  to  transfix 
and  hold  the  tumour  with,  tenacula  and  dissecting  forceps,  to- 
gether with  sponge,  and  a  long  bandage  being  prepared,  1  began 
my  operation  by  an  incision  carried  over  the  centre  of  the  tu- 
mour of  three  inches  long,  running  behind  the  line  of  the  jaw- 
bone, and  parallel  with  it  from  the  tip  of  the  ear  downwards; 
the  edges  of  the  skin  being  then  drawn  strongly  to  either  side, 
I  proceeded  to  dissect  the  tumour,  but  after  I  had. dissected  off 
the  fascia,  the  tumour  seemed  still  soft  and  shapelesss  ;  nothing 
like  a  firm  gland  or  circumscribi  d  tumour  appeared  ;  what  pre- 
sented under  my  knife  was  fiat  and  fleshy,  and  undefined  ;  and 
when  this  fleshy  mass  was  pinched  up  betwixt  the  finger  and 
thumb,  the  hard  tumour  was  distinguished  under  it:  I  now  re- 
collected that  I  was  cutting  directly  over  that  part  of  the  paro- 
tid gland  which  lies  behind  the  angle  of  the  jaw,  and  as  instant- 


P.  605 


N°17 


JBiS,  </,/? 


Lips,  Cheeks,  and  Throat.  505 

ly  distinguished,  that  the  surface  I  had  laid  bare,  was  no  other 
than  the  flat  white  granulated  substance  of  the  gland.  I  per- 
ceived that  the  tumour,  the  object  of  my  operation,  lay  under 
the  parotid  :  I  first  dissected  round  this  lobe  of  the  parotid  on 
each  side,  then  turned  off  the  lap  of  the  parotid,  or  that  lobe 
which  lies  behind  and  under  the  ear,  and  then  saw  the  indurated 
gland  lying  beneath  it. 

This  was  assuredly  a  delicate  piece  of  dissection ;  for  first 
the  lobe  of  the  parotid  was  turned  back  and  carried  behind  the 
angle  of  the  jaw,  at  that  point  where  the  division  of  the  external 
carotid  enters  into  its  substance.  Under  the  gland  lay  the  trunk 
of  the  carotid,  and  the  space  was  far  from  being  free  for  making 
so  dangerous  a  dissection  confidently:  there  was  no  want  of 
courage  on  the  part  of  my  patient,  but  it  was  somewhat  of  an 
obstreperous  and  boisterous  kind  ;  for  having  imagined  the  tu- 
mour a  simple  and  moveable  one,  to  be  cut  or  dug,  or  torn  out 
easily  and  quickly  ;  he  was  provoked  at  my  tedious  way  of  dis- 
secting, and  called  for  a  mirror  to  inspect,  if  not  to  direct  my 
incisions.  The  gland  itself  was  now  laid  bare  with  its  glistening 
bluish  capsule  of  cellular  substance,  and  while  the  lobe  of  the 
parotid  was  held  up  by  my  assistant,  I  dissected  cautiously  and 
slowly  into  the  angle,  to  separate  the  tumour  from  its  connec- 
tions. In  the  accompanying  sketch,  No.  17,  made  instantly 
after  the  dissection,  the  sides  of  the  incision  are  marked  (a  a) 
the  parotid  gland  held  upwards  by  a  hook  struck  through  the 
fascia  is  marked  (b),  the  tumour  lurking  under  it,  and  entirely 
enveloped  in  it,  (for  it  is  flat  and  cushion-like,)  is  marked  (c). 
The  operation  lasted  long,  and  was  not  a  very  tranquil  one :  but 
it  was  safe,  and  by  making  the  incision  merely  longitudinal, 
without  any  cross  incision,  and  immediately  under  the  whisker, 
and  by  pinning  it  nicely  and  delicately  with  fine  sewing  needles, 
and  laying  slips  of  court  plaster  curiously  betwixt  each  needle, 
the  adhesion  was  accomplished  in  a  few  days,  with  only  a  very 
slight  leaking  of  pure  saliva  from  the  wounded  surface  of  the 
gland  which  lasted  but  two  days,  and  in  eight  days  my  friend 
was  well  and  had  returned  home :  it  is  by  his  express  permis- 
sion, I  lay  this  slight  sketch  of  the  dissection  before  you. 

Slight  as  these  difficulties  may  appear  in  this  narrative,  it  is 
lit  you  be  aware  of  them  ;  for  the  young  surgeon,  in  the  moment 
of  seeing  something  altogether  unexpected,  a  flat  and  shapeless 
mass,  in  place  of  a  firm  circumscribed  gland,  is  in  danger  of 
losing  courage,  and  falling  into  confusion-  I  hope  I  need  not 
remind  you  how  unpleasant  an  accident  it  would  have  proved, 
had  a  young  and  thoughtless  operator  in  these  circumstances 
proceeded  rashly,  and  cut  across  the  parotid,  mistaking  it  for 
the  tumour,  or  cut  at  a  venture,  clown  into  the  angle  where  the 

n  S 


506  On  Tumours  of  the  Gums, 

Carotid  and  Portio  Dura  lie*  It  is  just  such  a  tumour  as  this, 
that  by  adhesion  and  induration  affects  all  the  surrounding  parts, 
becomes  too  formidably  connected  to  be  extirpated,  and  at  last, 
by  causing  cancer  and  destruction  oi  the  bones,  and  by  its  enor- 
mous size,  lays  the  patient's  head  upon  the  pillow  from  which 
it  is  never  to  b^.*  raised  again.  I  have  once  seen,  just  from  so 
slight  a  beginning,  a  boy  with  an  osteo-sarcomatous  tumour  of 
the  head,  where  bones,  muscles,  and  glands,  were  all  massed 
in  one  common  tumour,  big  as  the  original  head,  of  a  weight 
too  great  for  the  neck  to  raise,  and  which,  when  it  was  to  be 
moved,  was  moved  with  the  help  of  both  hands  ;  the  lad  uied 
of  stupor  and  apoplexy,  lrom  suppuration  ol  the  brain. 

It  has  often  struck  me  that  the  things  a  surgeon  ventures  to 
do  in  the  moment  of  operation,  resemble  in  one  respect  those 
which  a  soldier  does  in  mounting  a  breach :  what  is  past  looks 
like  a  dream,  and  upon  returning  to  the  scene,  and  considering 
the  danger  that  ;s  over,  he  shudders  at  his  hair-breadth  escapes, 
and  is  conscious  of  having  done,  what  he  can  never  venture  to  do 
again.  This  lias  been  especially  my  feeling  every  time  that  I 
have,  in  turning  over  my  case  books,  glanced  my  eye  on  the 
following  case  of  Jane  Sharp. 

Jane  Sharp,  aged  27. 

January  15th  M.  J.   Bell. 

"About  12  years  ago,  without  any  evident  cause,  she  ob- 
served a  small  very  painful  tumour  forming  immediately  un- 
der the  right  ear,  which  gradually  increased  for  four  years, 
until  it  had  arrived  at  the  size  of  a  large  goose's  egg,  rising  up 
anterior  to  the  ear.  At  this  time  she  had  it  cut  out;  during 
the  operation  she  lost  a  considerable  quantity  of  blood,  and  suf- 
fered great  pain  ;  since  which  she  has  been  unable  to  move  the 
muscles  of  that  side  of  the  face,  which  are  paralysed,  in  conse- 
quence of  the  division  of  the  Portio  Dura,  or  fascial  nerve. 
About  a  year  alter,  the  tumour  began  again  to  form,  accompa- 

*  The  fketch  of  this  diffcciion  explains  the  difficulty  and  delicacy  of  it.  The 
lobe  of  the  ear  is  marked  (a)  ;  it  was  lrom  the  hollow  betwixt  the  ear,  the  angle 
of  the  jaw,  and  the  vertebrae,  that  hollow  where  the  carotid  arteries  lie,  that  the 
tumouv  was  differed.  In  order  to  avoid  deformity,  1  had  made  the  incifion  lon- 
gitudinal only,  and  not  very  long,  no  more  than  three  inches;  (b)  marks  the 
lower  lobe  ol  the  parotid  gland,  which  in  its  natural  fituation  extends  almoff  to 
the  angle  of  the  jaw,  and  which  in  this  cafe  entirely  involved  the  lchirrous  gland  ; 
but  at  (£)  the  parotid  was  diflccled  from  the  furface  of  the  gland,  turned  up- 
wards and  held  afide  by  the  hook,  till  the  gland  (,.-)  was  diffecltd  out  from  be- 
neath it.  The  whole  appearance  of  the  parts  was  in  this  cafe  like  that  of  a  dif- 
fered hernia,  the  fafcia  of  the  gland  (J)  refenibled  in  fome  degree  that  of  the 
liLrniary  fac ;  the  parotid  refenibled  a  thickened  omentum,  which  being  turned 
afide  expufed  the  gland,  as  the  laying  afide  of  the  omentum  in  operating  for  her* 
niafhovvs  the  turn  of  the  incarcerated  interline. 


Lips,  Cheeks,  and  Throat.  SOT 

nied  occasionally  by  lancing  pains  ;  since  which  time  it  has  in- 
creased gradually.  It  is  at  present  about  the  size  of  a  large 
hen's  egg,  hard,  unequal  on  its  surface,  quite  colourless,  and 
at  times  accompanied  by  stinging  pains.  It  extends  considera- 
bly behind  the  jaw,  and  on  the  anterior  part  of  it  is  seen  the 
cicatrix  from  the  former  operation." 

1  rth. 
A  tolerable  night's  rest,  no  hamorrhagy,  but  she  complains 
of  pain  in  the  throat  and  difficult  deglutition. 

18th. 
She  complains  to-day  of  difficulty  of  breathing,  the  pain  of 
the  throat  continues,  the   bandage  being  slackened,  there    is  im- 
mediate  relief  to  both,  she  sleeps  ill,  opium  is  substituted  for 
the  draught. 

19th. 
Tlie  sponges  adhere  (irmly  to  the  surface  of  the  wound,  there 
is  l.ttle  tension  or  inflammation  of  the  parts,  but  she  still  com- 
plains of  the  pain  in  the  throat,  chieflv  on  deglutition. 

80th. 
Two  of  the  sponges    were  removed  with  little   difficulty   or 
pain,  no haemorrhagy.     The  wound  is  filled  up  with  lint. 

22d. 
All  the  sponge  is  removed. 

25th. 
The  discharge  is  copious. 

February  4th. 
The  cavity  fills  up  rapidly. 

'  15th. 
She  continues  to  do  well. 

25th. 
She  was  dismissed  nearly  well. 

Report  of  the  Operation  by  Mr.  Bell,  January  16. 
"  The  one  half  of  the  parotid  gland,  that  which  lies  behind 
the  angle  of  the  jaw,  had  be«.n  left  :  the  scar  of  the  former  ope- 
ration was  on  the  fore  part  ot  the  tumour  :  the  tumour  lay  be- 
hind and  under  the  ear,  pressing  deep  betwixt  the  mastoid  pro- 
cess, and  the  rising  branch  of  the  jaw-bone.  It  seemed  out- 
wardly a  small  tumour,  but  it  had  shot  down  very  deep,  ad- 
hering to  the  pteregoid  process  and  to  the  back  of  the  pharynx. 
The  dangers  of  the  operation  were  these  ;  the  portio  dura,  and 
the  9th  pair  of  nerves  passed  through  the  tumour  :  immediately 
under  it  lay  the  trunk  of  the  carotid.  The  external  carotid  be- 
hind the  lower  jaw,  but  chiefly  the  large  jugular  vein,  was  in 
danger,  for  the  tumour  lay  so  entirely  under  the  mastoid  mus- 
cle, that  part  of  the  muscle  is  taken  away  with  the  gland.     The 


oOS  On  Tumours  of  the  Gums, 

gland  being  dissected  free  in  its  lower  part,  where  it  lay  near 
the  carotid  artery,  was  torn  up  Irom  the  roots  where  it  ad- 
hered to  the  back  of  the  fauces.  The  internal  maxillary  arte- 
ry bled  very  profusely  ;  a  small  piece  of  sponge,  the  size  of 
the  thumb,  and  supported  by  other  pieces  ot  sponge  filling  up 
all  the  hollow,  was  pressed  upon  the  artery  at  the  back  ol  the 
nostril.  The  swelling  of  this  piece  of  sponge  caused  a  difficul- 
ty of  deglutition,  which  ceased  when  the  sponge  was  removed. 
After  the  operation  I  put  my  finger  into  the  hollow  whence  the 
gland  was  extracted,  which  I  ielt  to  be  two  inches  and  a  half 
deep  ;  at  its  lower  angle,  (i.  e.)  behind  the  corner  of  the  jaw- 
bone, the  carotid  lay  bare,  beating  strongly,  not  dilated ;  the 
upper  part  of  the  wound  was  deep,  so  that  the  finger  touched 
the  pteregoid  process  forwards,  and  the  apophysis  cuneiformis 
of  the  occiput  backwards  ;  and  when  she  swallowed,  the  mor- 
sel, in  passing  down  the  pharynx,  pressed  upon  the  point  of 
the  finger." 

When  it  happens  that  a  glandular  swelling,  small  in  its  first 
stage,  and  but  too  little  formidable  to  excite  alarm,  grows  in 
its  second  stage  to  such  magnitude  as  plainly  to  require  extir- 
pation, which  the  surgeon,  even  after  he  has  begun  the  opera- 
tion, dares  not  complete  ;  when  the  same  unhappy  person  pre- 
sents himself  again,  claims  the  assistance  of  the  surgeon,  will- 
ingly offers  to  subject  himself  to  any  operation,  however  severe 
or  cruel,  but  is  by  a  formal  consultation  rejected  and  bereaved 
of  all  hope  of  relief,  is  not  the  doctrine  explained  in  my  pre- 
liminary observations,  but  too  certainly  proved  ?  In  this  sense 
I  venture  to  call  your  attention  in  a  particular  manner  to  the 
case  which  I  am  now  to  relate,  and  to  the  reflections  which  oc- 
curred to  me  on  this  consultation. 

"  Jenny  Brown  was  a  poor  solitary  thing,  who  worked  la- 
boriously to  maintain  her  aged  mother,  her  lather  being  some 
years  dead:  she  slaved  at  all  kinds  of  work  as  an  out-serVant 
in  a  farm-yard.  After  churning  milk,  being  exceedingly  heated, 
she  went  out  with  her  cap  loobe,  and  jaws  exposed,  and  by 
carrying  bundles  of  wet  grass  lor  the  cows,  upon  her  head,  had 
a  severe  toothach,  for  which  a  tooth  was  pulled,  and  still  con- 
tinuing the  same  labour,  she  got  cold  ;  thence  arose  a  kernel- 
like  swelling  of  a  gland  under  the  lower  jaw  near  the  gum  of 
the  corrupted  tooth.  Her  face  was  swelled,  so  that  her  eyes 
were  closed ;  the  lump  grew  as  big  as  a  lien's  egg,  with  severe 
pain  ;  the  swelling  of  the  face  subsided,  the  pain  ceased,  but 
the  glandular  tumour  remained. 

Whenever  an  operation  is  ill-concerted ;  when  the  surgeon 
proceeds  to  extirpate  a  tumour  with  this  vulgar  notion  in  his 
head.  "  we  shall  try  to  take  it  away,"  he  is  almost  sure  to  fail  : 


Lips,  Cheeks,  and  Throat.  509 

accidents,  no  doubt,  will  prevent  the  most  dexterous  surgeon 
from  accomplishing  all  his  purpose,  and  a  zealous  man  will 
sometimes  attempt  what  he  dare  hardly  periorm  ;  but  a  sur- 
gewn  really  acquainted  with  the  uncertainties  and  difficulties 
oi  his  profession,  will,  even  in  the  least  dangerous  circum- 
stances, reflect  long  and  much  on  the  nature  ut  the  tumour 
which  he  is  to  extirpate,  and  the  anatomy  of  the  adjacent  parts  ; 
wiiether  it  consists  of  various  smaller  glands,  or  of  one  only  ; 
whether  it  has  its  arteries  lrom  one  point  or  stem,  so  that  it 
could  be  dissected  round  and  insulated,  this  point  being  left  to 
the  last  entire,  or  from  various  sources,  so  as  to  make  a  slow 
and  bloody  operation  necessary  ;  whether  these  aiteries  must 
be  cat  near  to  their  going  off  from  some  large  trunk,  as  the 
carotid  ;  whether  a  large  vessel  itself,  or  its  immediate  branches, 
may  not  be  entangled  in  the  roots  of  the  tumour.  Such  calcu- 
lations I  will  venture  to  say  never  entered  into  the  mind  of  the 
operator,  who  first  adventured  to  extirpate  this  tumour  :  he  en- 
tered upon  it  with  little  premeditation,  and  stopped  short  at  the 
first  slight  appearance  of  danger. 

To  extirpate  any  tumour  safely,  you  must  keep  to  its  sur- 
face ;  dissect  cellular  substance  only  ;  never  touch,  if  possible, 
its  system  of  vessels ;  if  once  you  plunge  into  its  centre,  you 
are  inundated  with  blood,  (unless  it  be  merely  a  steatoma)  and 
your  future  dissection  is  irregular  and  imperfect.  A  ver)  long 
incision  being  made,  the  operator  seemed  to  me  to  plunge  into 
the  very  heart  of  the  tumour,  several  arteries  (not,  it  is  mani- 
fest, of  very  dangerous  size,  for  he  had  never  even  approached 
the  roots  of  the  tumour)  threw  out  blood,  all  the  assistants 
thrust  in  their  fingers  to  stem  the  blood,  and  tin  operator  tak- 
ing advantage  of  this  consternation,  Little  confident'  in  himself, 
and  having  calculated  no  circumstance  beforehand,  obtained  an 
easy  and  unanimous  vote,  that  the  incision  should  be  sewed  up. 
This  was  to  me  manifestly  the  result  of  an  imperfect  know- 
ledge of  the  route  and  size  of  the  several  arteries,  of  the  error 
of  cutting  towards  the  centre  of  a  tumour,  and  of  the  worst  of 
all  faults  and  weaknesses,  that  of  turning  round  with  fear  and 
trepidation,  in  the  midst  of  occasional  difficulties,  to  consult 
those,  who  irom  the  moment  an  operation  is  begun,  should  be 
no  more  than  spectators.  It  proceeds  from  a  paltry  desire,  to 
make  the  attendant  surgeons  parties,  not  to  the  general  opera- 
tion, for  which  they  have  given  their  voice,  but  to  each  step  of 
it.  Let  the  surgeon  act  from  himself  according  to  the  best  of 
his  judgment,  cut  slowly  when  he  is  conscious  of  approaching 
too  near  the  great  vessels,  and  stop  when  alarmed  by  that 
immediate  sense  of  danger,  of  which  he  must  be  the  sole 
judge,  or  at  least  the  most  competent. 


510  On  Tumours  of  the  Gums, 

One  advantage  this  poor  creature  derived  from  this  unsuc- 
'  cessful  operation,  viz.  the  relief  from  pain,  lor  she  was  relieved 
by  the  loss  of  blood,  insomuch  that  she  recovered  her  health, 
and,  in  some  degree,  her  strength,  and  returned  to  work,  lor 
the  support  of  her  old  mother  ;  at  least  she  could  spin.  For 
a  long  while  she  has  been  unequal  to  this  ;  she  has  lingered  and 
wasted  in  a  very  helpless  condition,  and  is  now  in  a  state  of  ex- 
treme weakness  for  want  of  food  :  she  walks  but  a  lew  paces 
without  stopping  for  want  of  breath  ;  her  swallowing  is  diffi- 
cult ;  she  has  great  pain  night  and  day  trom  the  mere  distention 
and  size  (I  am  persuaded)  of  the  tumour,  which  is  not  red- 
dened in  tne  very  slightest  degree  :  the  weight  ot  the  tumour 
is  intolerable,  and  it  appears  to  me  that,  in  not  many  weeks, 
at  the  utmost  in  a  few  months,  she  must  be  released  from  her 
sufferings.  She  has  saved  one  shilling  to  enable  her  to  travel 
to  town,  from  the  village  she  lives  in,  (Falkirk)  which  is  about 
20  miles  distant  ;  and  now,  from  the  first  and  unsuccessful 
operation,  she  presents  herself,  after  no  great  lapse  of  time, 
with  a  tumour  so  enormous,  as  to  make  the  question  of  ope- 
rating difficult  to  resolve,  but  in  a  condition  which  admits 
no  delay,  she  is  sure  to  die,  and  willing  to  suffer  any  thing 
which  may  tend  to  save  her  life  :  there  is  one  inducement  to 
comply  with  her  request,  viz.  that  she  must  surely  die,  though 
from  no  other  cause  than  the  bulk  of  the  tumour  :  the  tumour 
not  being  cancerous,  leaves  us  nothing  to  dread  after  the 
operation. 

A  consultation  has  decided  that  no  operation  can  be  per- 
formed. I  imagine  there  are  very  many  safe  and  easy  ways 
by  which  this  tumour,  great  as  it  is,  may  be  extirpated,  or  de- 
stroyed ;  and,  reflecting  upon  the  possible  success  of  such  an 
attempt,  I  think  I  have  estimated  the  dangers  fairly,  and  as 
impartially  as  if  the  operation  were  my  own  appointed  task. 

This  poor  creature's  difficulty  of  breathing  seems  to  me  to 
proceed  as  much  from  the  weight  of  the  tumour,  as  from  the 
hold  it  has  upon  the  parts  ;  from  the  immense  mass  resting  up- 
on the  trachea  and  oppressing  even  the  breast.  The  tumour 
has  every  character  of  what  is  usually  called  a  wen  ;  the  whole 
mass  incredibly  hard  in  proportion  to  its  bulk,  so  that  she  sup- 
ports it  continually  with  a  sling  round  the  head  and  neck ;  it  is 
extremely  firm,  not  very  vascular  throughout  its  substance, 
but  receiving  its  arteries  at  particular  points  ;  it  has  no  great 
veins  running  over  its  surface,  whence  it  may  be  presumed 
that  it  has  no  very  irritated  circulation,  nor  any  thing  of  a  can- 
cerous nature.  The  whole  surface  of  the  skin  is  healthy  and 
free  from  redness  or  any  blemish,  except  where  the  scar  of  the 
former  operation  passes  obliquely  over  it  :  it  is  plainly  glandu- 


Lips,  Cheeks  and  Throat.  511 

lar,  the  most   prominent   parts  indeed  consisting  of  individual 
glands :  two   large  distinct  prominences   lying  one   beiore,  and 
another  behind  the  ear,  form  the  chief  bulk  of  the  tumour  at 
that  part,  and  art-  plainly  separate  glands,  moveable  both  in  re- 
lation to  each  other  and  to  the  main  tumour.     The  extirpation 
of  that   part  which  lies   under  the  chin  could  give  us   no  con- 
cern ;    there  we  could  cut  no  arteries  but  the    facial,    which 
would  be  divided  in  separating  the  tumour  from  the  line  of  the 
lower  jaw;   its  own  weight  seems  to  have   lengthened    its   root, 
and  drawn  it  down  from  under  the  ear,  and  from  the   angle  of 
the  jaw:   it  hangs  so  that  I  can  push  the  points  of  my  fingers 
deep  behind  it,  without  feeling  any   strong  adhesion,  and,  I  am 
confident,  it    has   no  dangerous  connection    with  the  carotid  at 
that  critical  point,  where  it  forks  behind   the  jaw-bone  into  the 
external  and  internal  carotids.      I  am  confident  that  the  carotid 
and  great  jugular  vein  lie  together  safe  in   their  sheath,  while 
the  tumour,   lying  external    to   the  sheath,   might  be  dissected 
away  from  it  :   from  the  mastoid  muscle,   and  horn  the  vessels 
beneath  quite  safely,  as  we  often  find   immense  tumours  of  the 
thigh  (equal  almost   in  size  to  the  patient's  bod\ )  are  dissected 
from  under  the  Sartorious  muscle,  without  injury  to  the  femo- 
ral artery.     The  worst  effect  of  the  tumour,  and  the  most  dan- 
gerous adhesions  of  it  are  to  the  side   of  the  throat,  to  the  os 
hvoides  and  its  muscles  ;  there,  by  pulling  down  the  os  h)  oides, 
it  makes  the  swallowing  difficult,  and  oppresses   the   breathing 
by  its  weight ;  and  at  that  point  there   might  be  infinite  trouble 
from  arteries  proceeding  into  the  body  of  the  tumour  from  those 
of  the  thyroid  gland.    But  the  tumour  is,  by  its  weight,  dragged 
so  awav  from  the  jaw,  and  admits  the  points  of  all   the  ni.gers 
ranged  in  a  line,  so  deep  on  all  sides,  that,  though  I  foresee  much 
difficulty,  I  find  no  absolute  danger  in  the  atti  mpt.     Yet  it  must 
be  done  by  one  who  goes  not  to  work  with  the  general  and  con- 
fused noiion,  of  extirpating  the  tumour  "  as  circumstances  will 
admit,''  and,  proceeding  according  to  the  best  of  his  judgment. 
His  judgment  must  be  decided  and  designs  matured  before  he 
begins;  he  must  calculate  at   what  points  the    arteries  enter; 
what  the  probable  size  of  those  that  come  from  under  the  chin, 
from  the  lingual  arteries ;   what  the  size   of  these  derived  to  it 
from  the  facial,  where  it  crosses  the  angle  of  the  jaw  ;  what  the 
size  and  probable  direction  of  those  coining  to   it  from  the  oc- 
cipital, or  temporal  bran;  hes  of  the  carotid  ;  or  those  deep  ones 
coming  from  thyroid  arteries  ;  he  must  resolve   in    what  suc- 
cession to  cut  them,  and  with  what  precautions.     The  surgeon, 
who  sees  an  artery  throw  out  blood  furiously,  and  in  the  neck- 
too,  not  knowing  from  what  root  it  comes,  must  instantly  fall 
into  great  confusion  :  but  if  he  has  calculated   every  probable 


512  On  Tumours  of  the  Gums, 

danger,  he  is  prepared,  and  his  patient  comparatively  safe. 
In  the  present  case,  the  incision  should  be  made,  not  over  the 
centre  of  the  tumour  ;  the  purpose  or  saving  all  the  skin  which 
invests  it,  is  absurd,  and  the  conception  of  dissecting  into  its 
substance,  extremely  ignorant.  The  oval  incisions  should  be 
made  to  encircle  its  upper  and  lower  parts  ;  there  are  points  in 
which  it  should  be  opened  freely,  as  there  the  chief  dissections 
are  to  be  performed.  The  great  and  dangerous  dissection 
would  be  in  the  line  of  the  lower  jaw,  about  three  inchts  irom 
it,  and  extending  from  behind  the  ear  to  the  throat :  the  skin 
being  laid  back,  this  dissection  would  follow  the  convtx  of  the 
tumour  ;  the  tumour  falling  by  its  weight  would  widen  the  in- 
cision and  expose  the  parts,  the  left  hand  laid  upon  it  would 
press  it  down,  while  the  assistant  retracted  the  skin  :  the  fore- 
finger of  the  left  hand  would  guide  the  dissection  ;  the  point 
of  it,  fixed  upon  each  lesser  artery  successively  as  it  bled,  would 
stop  it  till  it  shrunk  :  the  form  of  the  tumour,  the  line  of  inci- 
sion, and  the  direction  of  the  jaw-bone,  would  keep  the  relation 
of  parts  distinct:  the  operator  would  certainly  know  when  he 
approached  anv  dangerous  point ;  in  drawing  down  the  tumour, 
and  dissecting  it  from  under  the  chin,  he  would  cut  branches 
of  the  lingual  arteries  :  pressing  the  tumour  next  down  from 
the  angle  of  the  jaw,  he  would  cut  the  facial  artery ;  and  would 
go  no  further  in  that  direction  ;  having  tied  the  facial  artery, 
he  would  next,  in  tearing  away  the  tumour  from  under  the  ear, 
divide  branches  of  the  occipital  and  temporal  arteries  :  it  is  the 
seeing  those  arteries  bleed  furiously  in  succession,  without  fore- 
sight, without  knowing  from  what  trunks,  in  what  directions 
"they  come,  or  knowing  what  may  next  happen,  that  makes  an 
operation  seem  bloody  and  dangerous. 

In  next  dissecting  deep  into  the  angle  or  cavity  below  the 
jaw,  there  must  be  danger ;  every  incision  must  be  made  with 
caution,  the  point  of  the  fore-finger  must  go  before  to  feel  for 
the  beating  of  the  carotid  artery ;  and  much  should  be  done 
now  by  laceration,  the  tumour  being  inclined  first  from  the 
chin  backwards,  then  from  the  occiput  forwards,  and  pulled 
so  as  to  give  a  distinct  feeling  of  the  parts  with  which  it  is  con- 
nected, whether,  for  example,  pulling  upon  the  tumour  moves 
the  os  hyoides  fairly  along  with  it,  whether  the  tumour  sends 
down  roots,  involving  the  carotid  and  internal  jugular  vein : 
this  deliberate  and  daring  proceeding  would,  I  doubt  not,  en- 
able the  surgeon  to  approach  by  dissection,  or  laceration,  quite 
close  to  the  only  dangerous  point,  viz.  that  where  the  carotid 
lies  under  the  angle  oi  the  jaw  :  if,  having  reached  that  point, 
he  found  a  clear  and  distinct  cellular  substance,  to  lead  him  in 
his  dissection,   he  would,  pressing  aside   the  dangerous  parte 


Lips,  Cheeks  and  Threat.  51a 

with  his  finger,  continue  it  with  equal  deliberation  through  its 
next  stage  ;  if  he  found  inextricable  adhesion,  and  increasing 
haemorrhagy  he  would  stop  ;  but,  having  so  far  insulated  the 
tumour,  he  could,  if  forced  to  stop,  tie  its  root,  even  though 
several  inches  thick,  and  strangle  it,  if  not  with  a  surgical  li- 
gature, at  least  with  a  garter  or  coarser  string. 

I  should  not,  in  the  slightest  degree,  shrink  from  such  an 
operation,  and  would  dissect  so  very  large  a  tumour  with  less 
reluctance,  than  many  a  smaller  one  I  have  dealt  with.  I 
have  even  a  persuasion,  that  this  second  stage  ol  growth  may 
be  accompanied  with  circumstances  favourable  to  the  opera- 
tion, the  weight  of  the  tumour  elongating  its  roots,  weakening 
its  adhesions,  and  concentrating  its  arteries.  I  beg  leave  to 
remind  vou  of  another  circumstance  in  such  an  operation, 
which  you  will  do  well  to  attend  to.  Do  not  dissect  in  haste 
and  in  a  hurry,  for  by  time  and  circumspection,  vou  can  ac- 
complish things  which  seem  impossible,  and  I  would  explain 
mv  opinion  and  my  practice  more  fully  thus  :  M  Would  there 
be  much  danger  had  you  to  deal  at  once  with  one  only  ot  all 
the  arteries  which  are  cut  in  extirpating  a  tumour?"  None 
assuredly. — '*  Would  there  be  much  additional  danger  were 
the  pain  of  this  dissection  extended  from  a  quarter  of  an  hour 
to  an  hour  ?"  None.  Let  us  apply  this  reasoning  to  the  case 
before  us  :  I  have  uniformly  found,  that  permitting  the  blood 
to  stop  entirelv,  and  the  incisions  to  become  drv  before  bind- 
ing up  a  wound,  contributes  to  its  speedy  adhesion;  in  all  ope- 
rations I  wait  long  :  this  is  with  me  one  universal  rule  in  ope- 
rating. I  have  as  uniformly  found,  that,  when  a  dissection  be- 
came perplexed  and  confused,  the  taking  up  of  the  large  ves- 
sels, and  allowing  the  bleeding  irom  lesser  ones  to  cease,  and 
waiting  till  the  surfaces  get  that  raw  look,  which  betok<-ns  the 
drying  up  of  the  blood,  explains  every  thing,  and  restores  tha-: 
clear  conception  which  I  had  at  first  of  the  relation  of  parts,  ot 
the  arteries  I  have  actually  cut  and  tied,  and  of  those  which 
are  still  endang  xed  :  and  this  I  regard  as  a  rule  in  all  difficult 
operations.  In  dissecting  this  tumour,  or  such  a  one,  I  am 
convinced  that  the  danger  might  be  brought  within  very  nar- 
row limits,  and  am  confident  that,  in  the  present  instance,  even 
the  lower  lobe  ol  the  parotid  gland,  as  well  as  the  sheath,  con- 
taining the  carotid  artery  and  internal  jugular  vein,  lie  under 
and  behind  the  tumour;  in  short,  that  the  gland  lies  betwixt 
the  tumour  and  the  artery,  and  defends  it. 

But  are  there  not  various  ways,  independent  of  direct  inci- 
sion, for  working  out,  or  weakening  the  roots  and  adhesions 
ot  this,  or  even  of  a  more  formidable  tumour  \  May  not  a 
greater   enterprise   than  this   be  atchieved  bv  partial  incisions, 

3  T 


514  On  Tumours  of  the  Gums, 

by  ligatures,  or  by  both  combined?  The  two  great  globular 
knots  which  form  the  upper  part  of  the  tumour,  and  project 
before  and  behind  the  ear,  are,  I  am  persuaded,  so  insulated, 
that  they  might  be  dissected  away  by  one  operation,  reserving 
the  great  mass  of  the  tumour  for  a  second  :  or  the  operator 
might  go  as  far  as  he  safelv  could  bv  direct  incision,  and  then 
striking  a  long  needle,  like  those  with  which  1  have  been  ac- 
customed to  transfix  large  strumous  sacs,  puss  a  ligature  through 
th;  tumour  to  be  tied  on  cither  side  of  it  ;  or  the  tumour,  I 
am  persuaded,  might  be  so  pulled  away  from  the  throat,  and 
the  long  and  crooked  needle  I  speak  of  passed  so  cunningly 
round  and  under  the  tumour,  as  to  pass  the  ligature  round  it 
without  any  preparatory  incision.  It  is  possible  to  pmetrate 
so  into  the  body  ol  the  tumour  with  caustic,  as  to  pass  a  liga- 
ture through  its  centre,  and  after  extirpating  the  chief  mass  by 
stricture,  to  destroy  the  root  by  a  continual  use  of  the  caus- 
tic. It  is  possible  without  penetrating  into  its  centre,  to  dis- 
sect up  one  side,  or  to  pass  the  long  needle  obliquely  through 
one  side,  so  as  to  give  a  hold  to  the  ligature,  make  it  embrace 
the  neck  of  the  tumour,  and  by  twisting  it  with  a  tourniquet 
(made  by  twisting  a  stitch  in  the  ligature,  and  slipping  a  piece 
of  paste-hoard  under  the  knot)  from  day  to  day,  mortify  and 
extirpate  the  whole  mass.* 

But  there  is  no  need  for  subterfuges  in  a  plain  and  simple 
piece  of  dissection,  which,  though  not  without  danger,  is  vin- 
dicated by  the  suffocating  condition  of  the  patient,  and  by  the 
inevitable  nature  of  that  death  which  awaits  him,  an  operation 
which,  though  not  absolutely  safe,  is  so,  in  the  hands  of  a  dex- 
terous surgeon,  witness  the  following  most  interesting  case. 
The  most  considerable  tumour,  seated  in  so  dangerous  a  part 
as  the  neck,  which  I  have  ever  in  my  life  extirpated,  (says  M. 
Prtit)  occupied  all  the  side  of  the  face,  neck,  and  jaws;  it  was 
almost  entirely  circular,  extended  from  around  the  ear,  both 
b-  fore  and  behind,  upwards  to  the  angle  of  the  eye,  forewards 
to  the  corner  of  the  mouth,  and  downwards  over  the  jaw,  along 
the  neck,  to  the  articulation  of  the  clavicle  with  the  acromion 
process.     It  was  seemingly  eight  inches  in  diameter,  and  the 

*  My  reader,  unlefs  he  be  a  praiflical  furgcon  will  not  reaJily  ieel  the  reafon 
of  my  enumerating  thus  the  many  refources  which  will  present  thtmfelves,  nor 
the  fad  neceflity  of  having  recourfe  to  fo  many  means  What  dangers  in  the  way 
of  operation,  what  continued  tortures  by  any  flower  and  lefs  dangerous  method, 
will  not  a  man  undergo  to  fave  life  ?  This  poor  creature  probably  died,  as 
thoufands  have  died,  in  a  flate  of  protracted  fuffering ;  and  the  furgeon  who  has 
witneffed  fuch  a  fcenc,  who  has  felt  compunction  at  having  lightly  difmiffed  a 
patient  in  the  early  ftage  of  a  tumour,  which  has  afterwards  proved  fatal.or  who 
ru-  felt  the  difficulty  of  deciding  when  a  tumour  was  plainly  to  prove  fetal  Imt 
yet  too  deeply  connected  to  allow  of  extirpation,  will  think  over  all  the  poffible 
rcfources  with  fincere  intereft. 


Lips,  Cheeks,  and  Throat.  515 

patient,  about  50  vears  of  age ,  had  carried  it  twenty  years  ;  for 
it  wis  of  slow  giowth,  its  first  beginning  being  a  glandular  in- 
duration, seated  about  two  inches  under  the  ear,  and  lying  on 
the  mastoid  muscle. 

When  this  tumour  was  no  bigger  than  the  fist,  I  advised 
him,  and  often  repeated  the  advice,  that  he  should  have  it  ex- 
tirpated. When  he  refused,  I  prescribed  such  discutient  re- 
medies as  I  imagined  might  have  some  effect;  and  every  tune 
I  repeated  my  advice,  he  rejected  it  entirely,  because  he  could 
still  conceal  the  tumour  under  a  voluminous  peruke,  such  as 
was  then  in  fashion:  but  the  tumour  increasing  in  bulk,  so  as 
no  longer  to  be  concealed,  and  growing  so  painful  as  to  excite 
alarm,  he  convoked  a  number  of  surgeons  to  have  their  advice. 
I  alone,  of  all  the  gentlemen  consulted,  advised  the  extirpation 
of  this  tumour  ;  each  of  us,  as  the  consultation  was  not  held  in 
the  presence  of  the  patient,  spoke  his  mind  freely  ;  and  when 
it  came  to  my  turn,  I  explained  myself  thus  :  u  Of  all  the  rea- 
sons, gentlemen,  which  you  have  advanced  against  the  opera- 
tion, one  only  affects  me,  and  that  is  the  fear  of  h^morrhagy 
from  the  numerous  arteries  of  this  tumour,  which  not  having 
one  root  or  pedicle,  would  bleed  at  once  from  all  points,  and 
from  the  number  of  its  arteries,  some  most  likely  of  consider- 
able size,  the  patient  might  lose  much  blood,  perhaps  his  life. 
These,  said  I,  are  the  dangers,  but  have  I  not  skilful  assistants 
willing  to  stand  by  me?  What  then  should  I  fear?  I  shall  cut 
away  the  skin  along  with  the  tumour  which  it  covers,  because 
they  adhere,  I  shall  first  dissect  away  the  part  that  lies  over  the 
cheek,  and  some  one  of  you  appointed  for  that  duty,  shall  be 
ready  to  clap  a  finger  on  the  first  art.  ry  I  cut ;  and  as  I  pro- 
ceed in  my  dissection,  he  will  have  a  finger  ready  for  each  ar- 
tery that  springs.  Thus  shall  I  pursue  my  operation,  and 
whatever  number  of  arteries  are  cut,  so  many  fingers  will  there 
be  ready  to  compress  them  ;  and  the  whole  being  accomplished, 
finger  alter  finger  being  raised,  first  from  the  greater  arteries, 
and  next  from  the  smaller,  each  in  succession  will  be  secured 
with  the  needle  and  ligature.  The  scheme  was  acceptable  to 
all  of  them.  It  was  deferred  only  till  the  following  day,  and 
never  was  a  pr  ject  better  fulfilled,  for  never  perhaps  had  a 
young  surgeon  so  many  of  his  masters  in  surgerv  to  support 
him.  Arnould,  IYibauld,  and  the  elder  Le  Dran,  held  their 
fingers  on  the  arteries.  The  smaller  ones  ot  the  eye-lids,  lips, 
Sec.  were  considerably  dilated,  but  those  which  occasioned  the 
most  trouble  were  the  anterior  and  posterior  branches  of  the 
temporal  artery,  and  the  facial. where  it  turns  round  tin  lower 
jaw.     Each  ligature  held  its  place  ;  at  trie  first  dressing  not  a 


516  On  Tumours  of  the  Gums, 

drop  of  blood  flowed  ;  in  two  months,  or  little  more,  the  wound 
was  cicatrized."* 

You  will  observe  that  M.  Petit1  s  confidence  in  undertaking 
an  peration  so  formidable,  arose  from  a  conviction  of  the  tu- 
mour being  superficial  ;  not  under  the  mastoid  muscle,  but 
above  it;  not  connected  with  the  carotid  artery,  but  endanger- 
ing only  the  temporal,  and  facial  branches.  But  the  question 
is  a  very  awful  and  serious  one,  when  the  tumour  is  seated  be- 
neath the  mastoid  muscle,  projecting  from  under  it  in  conse- 
quence of  its  great  size,  and  probably  connected  at  its  root  with 
the  sheath  which  includes  the  carotid  artery  and  great  jugular 
vein:  such  a  tumour,  if  firm,  glandular,  growing  rapidly,  and 
pressed  inwards  bv  the  perpetual  bracing  of  the  mastoid  muscle, 
will  connect  itself  so  with  the  parts  beneath  bv  adhesion  as  to 
make  its  extirpation  dang  rous  in  the  last  degree,  and  it  will 
at  the  same  time  press  so  upon  the  throat  as  to  make  the  at- 
tempt an  act  of  necessitv  and  duty.  Often  I  have  had  occasion 
to  consider  the  anatomy  of  this  part  of  the  neck,  and  especial- 
ly of  the  vessels  and  nerves  lying  in  the  angle  under  the  jaw- 
bone, but  never  more  anxiously,  than  when  preparing  for  the 
following  operation.  The  subject  ot  it  was  a  gentleman  ;>bout 
35  years  of  age,  of  the  best,  and  most  grateful  dispositions, 
and  the  stoutest  heart.  He  confidently  required  me,  on  my 
allegiance  and  dut} ,  to  perform  the  operation  if  I  found  it  at  all 
consistent  with  safety,  although  it  had  been  forbid  in  ma- 
in former  consultations  with  other  surgeons :  his  courage  was 
not  in  words  onlv  While  I  performed  a  very  painful  and  siow 
dissection,  he  sat  like  a  monument.  The  tumour  projected 
from  under  the  ear,  of  a  stonv  hardness,  and  of  such  a  bulk  as 
to  fill  up  all  the  angle  betwixt  the  ear,  jaw-bone  and  neck  :  it 
extended  backwards  behind  the  ear  three  inches,  forwards  to 
the  chin,  and  downwards  along  half  the  neck ;  it  already  dis- 
placed the  larynx  and  throat,  pressing  them  over  towards  the 
left  side  ;  and  made  the  swallowing  difficult,  and  the  breathing 
so  laborious,  that  he  could  no  longer  sleep  at  night,  but  started 
out  of  bed,  partly  from  suffocation,  partly  from  fear  ;  it  in- 
creased withal  very  rapidly  in  size.  The  sum  of  the  opinion 
which  I  delivered  to  him  in  writing  was  this:  "  that  a  tumour 
so  situated  could  not  cease  to  grow,  and  could  not  fail  to  pro- 
duce, at  no  very  distant  period,  the  most  distressing  conse- 
quences: that  upon  comparing  the  tumour  with  the  great  ves- 
sels and  nerves  of  the  neck,  it  was  my  persuasion,  that  though 
it  lay  upon  the  great  rarotid  artery  and  jugular  vein,  it  had  n© 
essential   connection   with   them,   and  that   the   only   arteries 

*  Ouvrage  Pofthiime  de  J.  L.  Petit. 


Lips,  Cheeks  and  ThroctL  51 7 

which  would  be  unavoidably  cut  were  the  temporal,  occipital, 
and  facial  arteries:  that  the  carotid,  with  its  accompanying  i 
and  nerve,  were  involved  in  their  own  peculiar  sheath  ;  that 
the  angle  where  the  great  carotid  branches  into  the  th-  roid,  ki- 
cial,  occipital,  and  temporal  branches,  was  protected  by  the  Hi  is- 
toid  muscle,  and  by  their  sheaths  of  cellul  ir  substance  :  that  I 
thence  inferred,  that,  though  no  such  operation  can  be  void' of 
danger,  there  was  in  the  present  cast ,  nothing  i  d  ti  r  the  sur- 
geon from  attempting  bo  needful  a  dutv :  that  I  should  with 
pleasure  assist  at  this  operation,  or  with  equal  alacrity  pi  rf<  i  m 
it;  but,  that  I  conceived  it  a  necessary  privilege  that  the 
surgeon  who  made  himself  responsible  lor  the  life  of  a  patient, 
should  be  entitled,  in  all  irregular  operations,  especially  in 
one  so  full  of  danger  as  this,  to  stop  at  the  first  apprehension  of 
danger/' 

The  history  of  every  tumour  must  be  nlik^  :  and  I  foun  I  in 
the  historv  of  this  particular  tumour  nothing  i  iteresting.  Were 
I  inclined  to  draw  anv  inference, from  what  mv  patient  told  me 
of  th  origin  and  growth  of  this  tumour,  or  from  the  sev.  r«  a  id 
dangerous  operation  he  was  forct  d  to  subn  it  to,  it  would  be  that 
so  strongly  enforced  in  mv  Preliminary  Discourse:  viz.  That 
no  tumour,  when  it  passes  the  usual  limits  of  a  sw  -II -d  gland} 
and  begins  to  adhere  to  the  surrounding  parts,  should  be  per- 
mitted to  grow  ;  for  this  too,  like  that  of  Jennv  Brown,  was 
but  a  swelled  gland.  The  description  of  >verv  dangerous  tu- 
mour is  delivered  by  the  patient  in  the  same  phrase,  **  It  be- 
gan  like  a  little  knot  or  kernel,  and  grew  slowly  :"  it  is  there- 
for^  unnecessary  to  detain  you  with  insipid  and  trivial  details 
of  its  growth 

My  first  desire,  on  all  occasions  of  danger,  is  to  make  just 
conjectures  in  regard  to  the  internal  relations,  and  probable  ad- 
hesions of  the  tumour  ;  and  on  these  to  found  a  true  prognosis, 
to  be  delivered  to  the  patient,  or  his  friends,  and  a  rational 
s>.h  me  of  the  several  parts  and  steps  of  mv  intended  opera- 
tion. First,  I  found  the  tumour  of  very  formidable  dimen- 
sions, projecting  to  the  perpendicular  height  of  four  inches, 
and  terminating  in  an  apex,  which  stood  as  prominent  frnm  un- 
der the  ear,  as  the  chin  from  the  face  and  throat ;  and  this 
pointed  apex  was  the  smallest  part  of  the  tumour,  which  in- 
creased in  bigness  towards  its  base,  and  there,  especially  in 
the  part  lying  under  the  mastoidj  muscle,  though  it  was  move- 
able, because  the  muscular  parts  of  the  neck  are  moveable,  it 
se'-med  solidlv  connected  with  the  parts  beneath  it.  Secondly, 
though  that  never  could  be  regarded  as  a  superficial  tumour, 
whi  -h  lav,  in  its  biggest  part,  under  the  belly  of  the  mastoid 
muscle  :  yet  I  found  no  motive  for  despair,  ior  1  was,  by  eve* 


j  18  On  'tumours  of  the  Gums, 

ry  calculation,  persuaded  it  had  no  very  intimate  relation 
to  the  more  important  vessels,  but  stood  thus  connected:  it  lay 
so  close  upon  the  carotid  artery,  that  it  entirely  cow  red  that 
vcr\  dangerous  point  behind  the  angle  ol  the  jaw,  where  the 
carotid  forks  into  the  great  branches  destined  to  the  th\  roicl 
gland,  tongue,  lace,  and  temple  :  that  it  lay  closer  still  upon  the 
root  of  the  occipital  artery,  and  covered  the  whole  length  of 
the  facial  artery,  but,  though  deep  in  respect  of  the  mastoid 
muscle,  and  firmly  compressed  by  it,  it  was  superficial  in  respict 
of  the  carotid  artery,  for  the  angle  where  it  lorks  into  its  great 
branches  is  covered  by  the  st>  loid  process,  and  the  mustles 
arising  from  it;  and  is  even  bound  down  and  protected  b)  them. 
The  great  carotid,  the  jugular  vein,  and  the  eighth  pair,  were 
not  only  thus  protected  by  the  styloid  process,  and  muscles, 
but  are  farther  involved  in  their  peculiar  sheath  of  fascia.  It 
thus  seemed  to  me  less  dangerous  to  extirpate  even  this  great 
tumour,  than  the  smaller  one  of  Jean  Sharp,  seated  as  it  was 
deep  behind  the  ear,  were  the  carotid  artery  lies ;  yet  the  de- 
gree of  security,  arising  from  this  interposition  of  the  styloid 
process,  betwixt  the  angle  of  the  carotid,  and  the  bod)  of  the 
tumour,  onl\  rendered  the  operation  possible,  not  sale  :  there 
Were  other  manifest  dangers  to  be  encountered,  the  tumour 
passed  under  the  mastoid  muscle,  and  was  so  connected  with 
its  mner  surface  as  to  require  that  muscle  to  be-  turned  entirely 
backwards  in  dissecting  the  tumour  from  beneath  it ;  the  tu- 
mour could  not,  without  a  degree  of  danger,  be  detached  horn 
the  side  of  the  throat,  where,  as  it  seemed  to  me,  the  carotid, 
th«-  temporal,  and  occipital  arteries,  could  hardh  escape,  and 
where  the  inosculations  of  the  external  jugular  vein,  with  the 
gnat  internal  jugular,  would  not  fail  to  be  cut  across,  so  as  to 
cause,  if  not,  a  dangerous,  at  least,  a  very  perplexing  hsemorr- 
hagv. 

With  these  concepti  n^  I  formed  that  plan  for  the  operation 
which  succeeded  so  far,  as  to  carry  me  to  the  ver>  roots  ol  the 
tumour,  and  save  my  patient  from  very  imminent  clanger. 
First,  I  resolved  to  have  full  room  for  such  a  dissection,  iiiid 
to  carry  the  external  incision  obliquclv  across  the  neck,  in  the 
direction  of  its  natural  wrinkle,  following,  in  some  degree,  the 
edge  of  the  mastoid  muscle,  beginning  the  incision  on  the  oc- 
ciput three  inches  above  and  behind  the  ear,  and  ending  four 
inches  below  the  chin:  Secondly,  to  dissect  up  the  skin  large- 
ly and  widely,  and,  turning  it  back,  proceed  to  dissect  up  the 
mastoid  muscle  from  the  tumour:  Thirdly,  to  dissect  away 
dv  tumour  Irom  th(  lower  and  lesser  point,  where  it  projected 
from  under  the  mastoid  muscle  backwards,  but  not  far  ;  and  to 
dissect  it  next  down  from  the  ear  aud  from  the  chin,  towards 


Lips,  Checks,  and  Throat.  519 

the  place  of  the  carotid  artery  :  Fourthly,  the  tumour  and  the 
mastoid  muscle  being  moveable  in  respect  of  ach  other,  in 
place  of  merely  raising  up  the  tumour  gently  from  under  the 
mastoid,  with  the  design  of  dissecting,  resolved  to  poise  it  up 
strongly,  in  the  intention  of  tearing  it  away  trom  its  adhesion, 
and  gouging  it  out  with  my  fingers.  I  perceived  that  using 
my  knife  here,  though  it  might  not  much  endanger  the  carotid, 
would  wound  its  branches  close  to  the  trunk.  I  considered  la- 
ceration as  the  true  principle  ot  our  proceeding  in  all  such  dan- 
gerous points,  and  the  thrusting  in  a  piece  of  sponge,  as  the  best 
means  of  suppressing  any  occasional  haemorrhagy.  I  have 
gouged  out  tumours  with  the  fingers  *•  more  laniario,"  which  I 
should  never  have  dared  to  attempt  with  the  knife. 

From  this  plan  of  operation,  I  confidently  expected  that  there 
would  be  no  other  haemorrhagy  than  from  the  general  wound, 
viz.  blood  oozing  out  slowly,  from  the  cut-surfaces,  as  menstru- 
ation does  from  the  surface  of  the  womb  ;  unless  it  were  that 
sudden  gush  of  blood  which  flows  from  the  jugular  veins  when 
cut  across,  but  which  will  cease  instantly,  and  will  be  distin- 
guished by  its  black  colour  and  by  the  want  of  pulsation,  so  as 
not  to  create  even  a  momentary  alarm. 

This  plan  I  put  in  execution  with  great  success,  and  it  rests 
upon  my  own  mind  as  a  conspicuous  instance  of  an  operation 
performed  in  very  inauspicious  circumstances,  without  spilling, 
I  may  say,  one  drop  ot  blood,  where  it  seemed  difficult  to  es- 
cape wounding  even  the  greatest  arteries  ;  his  shirt  was  hardly 
moistened,  and  I  had  no  other  cause  of  alarm,  than  feeling  with 
the  point  of  my  finger  the  great  arteries  beating.  First,  the  out- 
ward incision  of  fully  eight  inches  long,  being  carried  round  the 
neck,  and  over  the  apex  of  the  tumour,  the  mastoid  muscle  was 
dissected  away  from  the  body  ot  it,  and  so  entirely  insulated, 
that  my  assistant  taking  it  on  his  fingers,  turned  it  before  or  be- 
hind the  tumour,  according  to  the  part  that  I  meant  to  dissect ; 
and  thus  I  d  ssected  sometimes  before,  and  sometimes  behind  the 
mastoid  muscle.  In  this  dissection  the  platysma  m\oides  mus- 
cle and  strong  fascia  of  the  neck  were  dissected  back  along  with 
the  skin.  Secondly,  in  dissecting  down  the  tumour  from  the 
occiput,  and  from  the  chin,  no  conspicuous  artery  bled,  and  my 
assistant,  while  I  dissected  along  the  line  of  the  jaw,  followed 
my  knife  with  his  finger-points  ot  both  hands,  go  arranged  in  a 
line,  and  following  the  incisions  in  its  whole  length  so  correct- 
ly, that,  by  holding  down  the  surface  from  which  I  was  dissect- 
ing away  the  tumour,  he  saved  the  arteries  which  might  other- 
wise have  been  cut,  and  was  ready,  had  an  artery  bled,  to 
cover  it  instantly,  and  make  its  place  by  clapping  the  point  of  a 
linger  upon  it;  and  thus  he  followed  the  dissection  oyer  the  an- 


520  On  Tumours  of  the  Gums, 

gle,  and  along  the  whole  length  of  the  jaw-bone,  repressed 
tlie  throat  where  the  lingual  arteries  and  nerve?  run  along,  and, 
bv  pressing  down  the  carotid  artery  and  its  sheath,  enabled  me 
to  cam  my  dissection  down  vu\  low,  I  dissecting  and  pull- 
ing the  tumour  awa\  from  the  jaws,  while  he  repressed  the 
parts,  at  one  time  with  the  line  of  his  lingers,  at  another  period 
of  the  dissection  with  a  long  flat  piece  of  sponge,  cut  for  the 
purpose.  Thirdly,  turning  the  mastoid  muscle  now  off  from 
the  tumour,  I  began  to  tear  upwards  and  dissect  the  lower 
pari,  that  which  projected,  according  to  the  natural  relation  of 
the  parts,  from  under  the  mastoid  muscle  at  its  back  part:  and 
here,  for  the  first  time,  I  found  reason  to  hesitate  ;  for  this 
p  rt  of  trie  tumour  was  connected  actually  with  the  spine,  it 
seem;  d  to  shoot  down  strong  thick  roots,  or  fangs,  betwixt  the 
transverse  processes  ;  the  external  branches  ot  the  nerves  which 
proa-.d  from  betwixt  the  cervical  vertebrae,  I  had  no  scruple 
nor  fear  of  dividing  across,  but  I  was  come  now  almost  to  the 
flat  fence  of  the  vertebrae.  I  was  going  deep  behind  the  pha- 
rynx and  the  sheath  of  the  carotid,  and  was  sensible  that  the  di- 
viding the  phrenic  nerve,  (for  the  principal  part  you  recollect  of 
the  third  cervical  nerve  is  destined  for  the  diaphragm,)  would 
probably  prove  latal.  The  harm  1  might  do  was  terrible,  the 
good  problematical;  very  little  of  the  tumour  remained,  it  was 
such  as  even  my  assistant  could  hardly  perceive,  much  less  a 
spectator,  but  I  found  myself  not  entitled  to  venture  farther,  I 
therefore  cut  th.se  roots  across,  and,  having  thus  delivered  the 
patient  from  this  tumour,  I  felt  the  great  chasm  left  by  it- — 
Now,  Gentlemen,  I  am  explaining  these  matters  for  your  in- 
struction, and  the  good  ot  humanity,  and  with  thoughts  far 
above  any  politic  regard  for  mv  own  reputation,  such  as  might 
tempt  me  to  conceal  or  palliate  any  fact:  the  little  portion  that 
was  left  of  this  tumour  I  could  hardly  feel:  1  had  no  misgiv- 
ing in  my  own  mind  beyond  that  vague,  indefinable  anxiety, 
which  an  upright  man  should  feel  after  an  operation,  however 
promising,  and  which  I  have  never  failed  to  suffer  from,  even 
where  most  successful,  for  I  am  ev>  r  apt  to  imagine,  that  I 
might  have  performed  the  operation  better,  and  this  was  all  I 
felt  at  the  time,  it  was  only  by  future  consequences  that  I  was 
struck  with  regret  for  not  venturing  a  little  deeper  *  The 
chasm  left  by  the  extirpation  of  the  tumour  I  next  examined  ; 
the  dissected  mastoid  muscle  lay  loose  and  flapping,  and  we 
turned  it  occasionally  over,  from  one  side  to  the  other,  to  look 
for  bleeding  vessels,  but  there  were   none,  there  was   nothing 

*  The  tumour,  in  little  more  than  a  year,  hegan  to  grow  again  ;  and  it  is  now, 
at  the  diftance  of  two  years,  as  large  as  at  the  time  of  the  operation. 


Of  Salivary  Tumours.  521 

*but  the  very  slightest  general  oozing,  the  surfaces  were  dressed 
with  lint,  with  a  very"  gentle  compression  :  the  wound  suppu- 
rated favourably,  and  healed  within  the  month  :  but  the  tumour 
has  grown  again  to  a  great  size.  Such  are  the  difficult,  and 
distracting  circumstances  to  which  those  are  reduced  who,  from 
their  own  timid  dispositions,  or  the  ignorance  of  their  medical 
friends,  have  allowed  an  indurated  gland  to  grow  and  fasten 
itself  by  adhesions,  to  the  surrounding  parts,  and  to  push  its 
roots  deep  into  the  neck,  or  axilla. 


DISCOURSE  XXV. 


Of  Salivary  Tumours. 

JjUT  it  is  not  the  discussing  of  interesting  doubts,  and  ques- 
tions of  life  and  death,  nor  the  performing  operations  within 
the  extreme  limits  of  possible  success  or  possible  safety,'  that 
constitutes  the  chief  occupation  of  one  engaged  in  practice. — 
The  more  homely  talent  of  distinguishing  the  various  aspects 
and  characters  of  tumours,  and  treating  them  judiciously,  is  far 
more  desirable  to  acquire  ;  and,  indeed,  there-  is  a  very  per- 
plexing variety  of  tumours  within  the  mouth,  and  round  the 
jaws,  which  one  learns  to  distinguish,  only  by  referring  their 
various  aspects  to  corresponding  peculiarities  in  the  structure 
of  the  parts.  The  tumours  which  I  have  just  described  are  of 
a  very  malignant,  character,  and,  I  confess  I  know  not  whether 
to  refer  them  to  the  salivary  or  the  lymphatic  glands  ;   to  the 

latter,  rather,  I  believe.     This,  for  example,  of  Mr.  M , 

though  it  looks  like  a  tumour  of  the  sub-maxillary,  I  know  to 
be  a  tumour  of  the  lymphatic  glands :  had  it  been  a  tumour  of  the 
sub-maxillary  gland,  which  holds  imbedded,  I  may  say,  in  its  sub* 
stance,  the  facial  artery,  it  could  not  have  been  extirpated  without 
dividing  that  artery  :  the  sub-maxillary  gland  is  divided  into  two 
masses,  and  the  trunk  of  this  arterv  is  received  into  the  recess 

3U 


522  Of  Salivary  Tumours, 

or  cleft,  the  artery  seems  to  twist  round  the  gland,  and  I  have, 
both  in  extirpating  the  sub-maxillarv  gland,  and  in  assisting  at 
such  operations,  recognized  it  by  this  mark. 

The  following  case,  if  not  full  of  interesting  particulars,  is, 
at  least,  accompanied  with  useful  rules  ;  and  I  transcribe  it 
from  mv  case-book,  with  those  reflections  which  arose  in  my 
mind,  when  forming  my  opinion  and  preparing  for  the  opera- 
tion, as  I  have  ever  done  with  a  scrupulous  and  conscientious 
desire,  to  foresee  every  eventual  danger,  and  recollect  every 
circumstance,  anatomical  or  pathological,  which  might  contri- 
bute'to  mv  patient's  good  :  the  reflections,  you  will  perceive, 
bear  a  mutual  relation  to  the  instruction  of  my  pupils,  and  my 
own  improvement.  It  is  the  case  of  a  young  Lady  who  came 
from  a  very  great  distance,  urged  by  her  own  fears,  and  the 
persuasions  of  her  surgeon,  whose  letter  I  shall  transcribe. 

Shetland,  Aug.  14,  1802. 
"  Sir, 
"  Though  I   have   not  the  honour   of  being  personally  ac- 
cmainted  with  you,  yet  from  the  eminent  and  justly  distinguish- 
ed character  which  you  hold  in  the  world,  and  from  my  own 
observation   of  your  superior  skill  and  abilities,  I  beg  you  will 

receive  Miss  N ,  a  particular  friend  of  mine,  under  your 

professional  care.  She  has  for  more  than  three  years  had  an 
enlargement  of  one  of  the  glands  under  the  jaw,  which  gave  her 
not  the  slightest  uneasiness,  till  of  late  that  she  has  begun  to  feel, 
occasionally,  some  pain  from  it,  which  has  induced  her  to  take 
this  journey,  in  order  to  have  the  real  nature  and  tendency  of 
the  tumour  determined  ;  and  to  submit  to  any  thing  you  may 
judge  most  proper.  In  the  full  confidence  of  your  affording 
her  every  attention  in  your  power,  I  remain,  with  esteem,  your 
most  obedient. 

"  John  Barclay,  Surgeon/' 

OBSERVATIONS. 

Every  new  operation,  I  perceive,  will  afford  for  my  pupils 
some  new  rule  of  surgery,  and  prove  to  myself  a  source  of  in- 
struction ;  and  the  various  lessons  which  we  derive  thus  from 
experience,  are  such  as  no  conjecture  nor  previous  study  of  the 
parts  will  enable  us  to  anticipate  ;  nothing  but  a  long  continued 
and  faithful  attention  to  practice  can  make  a  surgeon  skillul,  or 
enable  him  to  give  lessons  to  others. 

1st.  I  observe  in  this  lady's  case,  that  the  gland  affected 
seems  to  be  the  very  gland,  which  after  an  unsuccessful  opera- 
tion, grew  to  so  immense  a  size  in  the  case  of  Jenny  Brown  ,- 


OfSaltvarij  Tumours.  523 

and  in  her,  though  the  tumour  arose  from  the  slightest  and 
most  accidental  c;iuse,  without  any  cancerous  diathesis,  or  other 
malignant  tendency,  it  proved  iatal  by  suffocation,  the  most 
miserable  kind  of  death.  What  might  have  become  ol  this 
lady  it  is  easy  to  foresee,  had  she  not  been  warned  by  her 
surgeon,  and  alarmed  by  the  recent  accession  of  pain  for  her 
own  safety. 

2d.  When  we  are  consulted  what  is  to  be  done,  in  anv  par- 
ticular case,  we  are  in  other  terms  called  on  to  prognosticate 
what  will  be  the  patient's  condition  at  the  distance  of  one  or 
two  years  :  in  the  present  case  the  gland -is  very  large  and  of  a 
stony  hardness,  it  never  can  suppurate,  it  is  even  threatened 
with  a  cancerous  inflammation,  it  is  indeed  incapable  of  any 
other  ;  the  pain  requires  that  something  should  be  resolved  on, 
and  our  prjgnostic  may  be  safely  grounded  on  this  unques- 
tionable assumption,  that  such  a  tumour  will  not  fail  to  grow, 
and  that  in  one  or  two  years  the  deformity  and  bulk,  will  of  it- 
self be  a  motive,  while  the  suffocating  condition  of  the  patient 
will  be  an  absolute  reason  for  operating,  however  dangerous 
the  opt  ration  maybe  rendered  by  such  unwise  delay.  It.  is 
moreover  to  be  observed,  that  the  gland  is  the  sub-maxillary 
gland,  which  has  the  facial  artery  nitched  in  betwixt  its  two 
lobes,  not  so  inextricably  indeed  as  the  parotid  is  connected 
with  the  carotid  artery,  but  in  a  degree  to  give  alarm  and  trou- 
ble to  the  surgeon,  and  accompanied  with  a  degree  of  danger 
(in  the  case  of  operation)  which  is  well  worth  calculating. 

3d.  We  are  to  regard  the  actual  circumstances  of  every  pa- 
tient, as  a  part  of  his  case,  and  the  danger  to  this  lady,  if  re- 
manded to  her  own  country,  so  far  distant,  and  so  difficult  of 
access,  is  but  too  palpable.  Should  we  speak  to  her  the  usual 
temporising  language,  and  say,  "  it  will  perhaps  get  well,  a 
slight  course  of  mercury  or  cicuta  may  be  useful,  and  time  may 
do  much,  and  perhaps  it  may  be  well  to  wait."  It  may  hap- 
pen that  the  gland  may  become  stationary  in  its  growth,  a  mer- 
curial course  may  be  of  use,  but  I  fear  that  this  is  in  the  truest 
sense  tampering  with  a  tumour,  and  that  time  can  do  nothing 
but  increase  the  danger.  It  seems  to  me  but  too  possible,  that 
this  ladv,  before  she  can  take  a  second  resolution,  and  accom- 
plish a  second  journey,  will  be  suffocating,  and  in  immediate 
danger  of  life  :  then  we  shall  not  venture  to  do  that  operation, 
which  is  now  comparatively  easy ;  for  this  gland  being  seated 
in  the  angle  betwixt  the  trunk  of  the  carotid  arttry  and  one  of  its 
great  branches,  the  maxillary  or  facial,  will  distend  that  angle, 
and  both  the  trunk  and  its  branch  will  be  too  closely  united 
with  the  tumour  to  admit  of  an  operation :  or  will  make  the 
operation  most  dangerous  and  critical. 


524  Of  Salivary  Tumours. 

4th.  Though  there  is  no  imminent  danger  in  the  proposed 
operation,  the  circumstances  are  sufficient!)  forbidding  to  make 
it  far  from  being  a  matter  of  choice,  Mj  assistant  was  unwil- 
ling that  it  should  be  performed  without  the  ad  Dr. 
Munro,  and  his  assent  seemed  rather  reluctant*  The  tnm«  ur 
is  of  very  considerable  size,  it  is  plaint)  the  sub-maxillary 
gland,  as  may  be  inferred  from  its  shape,  size,  and  peculiar 
hardness  ;  not  a  lymphatic  gland,  for  then  most  likely  more 
than  one  would  be  enlarged.  We  must  be  resolved  to  deal 
with  this  arttrv  in  one  of  two  wa\  s  ;  either  to  dissect  it  so  from 
the  tumour,  as  to  insulate  the  arurv,  and  turn  the  tumour  from 
under  it ;  or  should  this  attempt  threaten  to  embarrass  our  ope- 
ration, to  cut  it  across  where  it  lies  over  the  middle  of  the  tu- 
mour, tying  before  dividing  it,  lest  it  should  shrink  back  to- 
wards its  trunk.  No  one  circumstance  is  so  favourable  to  the 
operation,  as  that  extreme  hardness  of  the  tumour,  which 
makes  the  operation  necessary  ;  for  that  shews  it  to  be  circum- 
scribed, and  to  be  little  connected  by  inflammation,  with  the 
cellular  substance. 

NOTES  OF  THE  OPERATION. 

We  had  agreed  either  to  dissect  so  as  to  lay  the  artery  to  one 
side,  while  employed  in  extirpating  the  gland.;  or  to  tie  and 
cut  across,  and  so  proceed  with  greater  freedom,  in  the  more 
dangerous  part  of  the  dissection  ;  but,  after  the  first  incision 
which  I  made,  according  to  the  length  of  the  jaw-bone,  the  in- 
cision being  long  and  more  free,  the  several  parts  appeared  in 
so  advantageous  a  state,  as  to  leave  no  doubt  or  difficulty  in 
the  rest  of  our  proceedings.  The  artery  presented  itself  arch- 
ing over  the  diseased  gland,  much  elongated  and  terpentine  j 
so  that,  in  place  of  embarrassing  the  operation  with  any  need- 
less delicacy,  or  endangering  the  shrinking  up  of  such  an  arte  - 
ry  towards  its  trunk,  we  passed  two  ligatures  of  single  thread 
under  it,  cut  betwixt  the  ligatures,  and  then  proceeded  more  con- 
fidently in  extirpating  the  gland  :  there  we  found  no  such 
hesion  of  it  to  the  trunk,  or  rather  to  the  sheath  of  the  carotid, 
as  we  had  reason  to  apprehend  ;  the  tumour  was  of  such  ■ 
ny  hardness,  the  cellular  substance  so  loose,  the  arteries  BO  di  - 
engaged  from  it,  that,  without  the  help  of  the  knife,  with 
the  swallow-tailed  end  of  its  handle,  which  I  used  as  a  scalp«  I, 
I  turned  out  the  tumour  in  a  few  seconds,  and  the  tumour 
carrying  its  cellulur  substance  along  with  it,  the  styloid  muw  Is 
were  left  as  clean,  distinct,  and  bare,  as  after  a  neat  dissection 
in  the  dead  subject. 

In  regard  to  ooerations  where  blood-vessels  of  great  size  arc 


Of  Salivary  Tumours.  325 

endangered,  or  actually  wounded,  I  think  I  may  safely  pro- 
pose those  simple  rules  to  my  pupils  for  their  general  con- 
duct. 

1st.  To  consider  well  the  anatomy  of  the  natural  parts,  and 
the  probable  connections  of  the  tumour,  so  as  not  to  plunge  un- 
advisedly into  difficulties,  which  may  unnerve  his  hand  in  the 
most  critical  moment  ;  never  to  endanger  anv  unexpected 
bursting  out  of  blood,  such  as  might  cause  alarm  :  for,  to 
wound  an  important  artery,  without  having  foreseen  the  possi- 
bility of  so  doing,  or  to  encounter  anv  danger  of  this  nature, 
without  having  approached  it  by  slow  and  delicate  dissection, 
and  provided  against  the  sudden  eruption  of  biood,  by  concert- 
ing with  his  assistant,  what  is  to  be  done  in  each  possible  case, 
would  be  an  indelible  disgrace  to  the  surgeon. 

2nd.  The  surgeon,  while  he  approaches  a  dangerous  point  with 
all  possible  circumspection,  and  with  precaution  amounting  al- 
most to  timidity,  and  tries  to  avoid  anv  important  artery,  or  is 
carelul  as  he  approaches  it,  to  distinguish  it  by  its  place,  to  feel 
it  with  his  finger,  to  dissect  so  as  to  avoid,  or  to  tie  it,  should, 
the  moment  the  artery  he  tears,  or  anv  artery  is  wounded,  and 
blood  bursts  out,  dismiss  all  fear,  then  let  courage  and  rapid  ex- 
ecution take  place  of  fear,  or  circumspection  :  let  him  plunge 
his  finger  down  to  stop,  or  to  catch  the  artery,  or  dive  with 
his  needle  to  surround  it.  If  there  be  nerves,  important  nenes, 
as  in  the  axilla,  which  are  endangered  by  this  stroke  ot  the  nee- 
dle, he  must  be  prepared  to  decide  instantly  how  far  the  danger 
authorises  such  a  plunge.  If  the  long  course  of  the  wounded 
artery  gives  him  room  to  seek  it  at  another  point,  he  must  be 
prepared  instantly  to  run  his  knife  backwards  along  its  course? 
or  to  cut  with  his  scalpel,  or  plunge  with  the  needle,  into  the 
hollow  where  it  lies,  without  a  moment's  delav  ;  a  man  who 
is  not  prepared  for  this  by  his  knowledge  of  the  blood-vessels, 
and  able  for  it  by  his  courage  and  presence  of  mind,  is  no  sur- 
geon. 

Thus,  circumspection  and  daring  have  each  their  peculiar 
point  ol  time  ;  neither  is  to  be  regarded  as  forming  a  promin- 
ent leature  in  the  temper  of  the  surgeon  ;  but  that  knowledge  of 
parts,  and  firmness  of  mind,  which  prescribes  circumspection 
and  caution  in  approaching  a  dangerous  point,  will  ensure  con- 
fident and  rapid  execution,  when  danger  is  actually  present. 

3d.  The  surgeon,  when  he  speaks  of  courage,  must  always 
distinguish  the  discreet  and  deliberate  boldness  which  belong 
to  his  professional  character,  from  the  personal  bravery,  or 
foot-hardy  contempt  of  danger,  which  he  is  entitled  to  indulge 
in  his  own  individual  case;  it  may  to  himsell  seem  heroic,  or 
gallant,  to  endanger,  or  to  throw  away  life  ;  but,  when  respon- 


526  Of  Salivarij  Tumours. 

sible  for  that  of  a  fellow-creature,  he  has  no  such  latitude  of 
sentiment  or  action,  and  must  be  guided,  not  by  feeling,  but 
reason.  So  strictly  is  he  bound  to  avoid  danger,  that  he  is  ac- 
tually bound  to  afflict  his  patient  with  protracted  and  severe 
pain,  to  ensure  his  safety  ;  and  to  endure  the  unmerited  re- 
proaches of  whatever  ignorant  or  ill-judging  person  may  choose 
to  report  his  operations  as  awkward  or  slow.  Dispatch  and  a 
show  of  dexterity  will  ever  be  a  poor  apology  for  endangering 
life  ; — and  pain,  a  bad  reason  for  hurry  or  perturbation,  where 
loss  of  blood  may  be  the  forfeit ;  the  pain  of  pulling  the  stump 
of  a  corrupted  tooth  is  more  severe  and  often  more  protracted 
than  that  of  the  most  important  operations  ;  the  pain  cf  simple 
incisions  is  never  deadly. 

4th.  Protracted  pain  is  attended  with  danger,  only  in  those 
operations  whtre,  from  such  torturing,  inflammation  of  some 
internal  part,  or  great  cavity,  as  the  knee-joint,  the  thorax,  the 
abdomen,  may  ensue. 

There  is  another  species  of  tumour,  of  a  complexion  the 
most  opposite  possible  to  this  ;  a  vesicular  transparent  tumour, 
seated  on  the  tongue  :  as  the  hydatid  of  the  testicle,  brain,  li- 
ver, &c  was  long  supposed  to  be  a  mere  enlargement  of  a  lym- 
phatic vessel,  this  clear  vesicular  tumour  on  the  tongue  has  been 
supposed  to  be  a  mere  distention  of  the  sublingual  ducts,  which 
are  indeed  delicate  and  transparent,  and  lie  in  this  direction  be- 
neath the  tongue.  One  instance  of  this  disease  occurred  in  an 
infant  on  the  breast ;  the  tumours  had  continued  for  several 
months,  had  been  punctured  three  times,  but  returned  inces- 
santly, and  had  grown  to  such  a  size  as  to  prevent  the  child 
'sucking,  by  turning  the  tip  of  the  tongue  away  from  the  nip- 
ple :  there  were  three  vesicles,  two  of  which  lay  in  that  place 
and  direction  which  correspond  with  the  situation  of  the  saliva- 
ry duct,  but  the  third  affecting  more  the  tip  of  the  tongue,  de- 
monstrated how  futile  this  common  idea  is,  for  this  third 
vesicle  Was  situated  altogether  out  of  the  course  of  the  ducts. 
These  vesicles  are  merely  accidental ;  they  are  stationary, 
which  they  would  not  be,  if  they  were  dilatations  of  the  duct ; 
they  pour  out  no  more  fluid,  than  what  the  vesicle  itself  con- 
tains, which  would  not  be  so  if  they  were  connected  with  the 
salivary  gland  ;  upon  being  punctured  they  rise  again  in  a  week 
to  their  original  size  :  this  had  been  so  punctured,  and  had  re- 
turned three  successive  times.  A  more  singular  appearance 
cannot  be  seen  than  such  a  pure  and  pellucid  vesicle,  projecting 
from  the  red  and  moist  surface  of  the  tongue  ;  it  is  harmless, 
and  seldom  in  child  or  adult  arrives  to  any  considerable  size  ;  it 
,'s  stationary,  for  I  have  seen  it  continue  in  children,  or  in  young 


Of  Salivary   Tumours..  527 

people,  for  years,  without  harm  ;  when  slit  open,  it  leaves  no 
sore,  nor  even  a  discernible  mark,  but  in  a  week  it  is  just  what 
it  was  before  :  I  have  found  no  way  of  ridding  the  patient  of 
this,  which,  in  a  child,  is  but  an  inconveniency,  but  in  an  infant 
prevents  sucking,  but  to  tranfix  the  vesicle  with  a  little  hook  and 
cut  it  freely  out  with  scissors. 

A  proper  tumour  of  a  salivary  gland  is  more  frequent  in  the 
adult,  and  is  truly  a  formidable  disease  ;  for  the  salivary  glands 
are  inclosed  by  the  muscles  of  the  throat  and  tongue,  the  sub- 
lingual gland  especially,  which  lies  under  the  tongue,  is  cover- 
ed by  the  genio-glossi  and  hyo-glossi  muscles,  it  is  thence  so  in- 
vested with  thick  masses  of  flesh,  and  so  compressed,  that, 
when  it  falls  into  disease,  the  collected  fluid,  unless  it  should  be 
pus,  cannot  make  its  way  through  so  great  a  thickness  of 
parts;  it  continues  for  years,  and,  if  idly  punctured,  without 
any  care  being  taken  to  obliterate  the  sac,  or  distended  part  of 
the  gland,  repeated  distention  of  it,  accompanied  with  inflamma- 
tion, so  thickens  the  root  or  vascular  part  of  the  gland,  that  it 
.grows  into  a  solid  tumour,  sometimes  fatal,  by  compressing  the 
throat  and  tongue.  Misconduct  in  not  distinguishing  such  tu- 
mours, in  not  obliterating  very  carefully  the  cavity  of  all  saccu- 
lated tumours  of  ( the  neck,  and  in  not  preventing  the  formation 
of  firm  and  indissoluble  roots,  or  bases,  is  an  error  so  very  fre- 
quent that  I  think  I  cannot  do  you  a  greater  kindness,  than  to  lay 
before  you  a  few  examples  as  documents. 

"  Margaret  Murray,  a  woman  about  fifty  years  of  age,  had 
crawled  from  one  of  the  miserable  Edinburgh  closes  into  the 
Infirmary,  asthmatic  and  suffocating,  with  one  of  the  most  for- 
midable and  bulky  tumours  I  had  ever  seen  ;  it  resembled  that 
of  Jenny  Brown  in  siuation  and  nearly  in  size,  but  its  nature 
was  altogether  different.  Her's  was  throughout  of  a  stony 
hardness  ;  this,  though  of  a  degree  of  hardness  resembling  a 
cartilage,  was  hard  only  on  its  surface,  while  there  was  within 
an  obscure  fluctuation,  which  determined  my  opinion  both  of 
its  nature,  and  of  what  should  be  done.  The  tumour  was  as 
big  as  the  patient's  head,  it  stuck  close  under  the  jaw,  and  so 
compressed  the  throat  that  the  poor  creature  lay  gasping  for 
breath  ;  the  least  necessary  motion  in  putting  out  her  hands,  or 
struggling  to  raise  herself,  threatened  suffocation  :  her  eyes 
were  staring,  her  nostrils  widely  dilated,  and  her  hands  grasping 
every  thing  near  her  as  if  for  help ;  her  friends  supported  her 
perpetually  in  the  recumbent  posture;  her  face  was  livid,  and 
the  lips  purple  with  stagnant  blood  ;  the  tumour  itself  was  uni- 
versally lurid,  or  of  a  deep  purple  cast,  as  if  verging  towards 
gangrene;  and  indeed  I  doubt  not  if  it  had  been  possible  for 
the  woman  to  have  survived  in  this  condition,  it  must  haye  fall- 


528  .    Of  Salivary  Tumours, 

en  into  gangrene ;  it  seemed  so  solid  withal,  that  the  surgeoa 
was  doubtful  what  should  be  done,  and  refused  to  puncture  it. 
My  importunate  representations  at  length  prevailed,  and,  at  an 
irregular  hour,  and  in  no  wry  regular  way,  it  was  punctured  ; 
a  trocar  too  small  for  sut-h  a  purpose,  was  plunged  into  the  tu- 
mour ;  the  matter  which  flowed  was  thick  and  ropy,  like  that 
which  is  most  frequently  discharged  from  a  diseased  ovarium  ; 
it  resembled  sago  made  with  port  wine;  about  two  pounds 
flowed  without  any  sensible  diminution  of  the  tumour.  It  was 
expected,  that  this  first  discharge,  and  the  thinner  gluten  which 
afterwards  flowed,  would  give  relief;  but  those  who  indulged 
such  an  expectation  did  not  recollect,  that  to  produce  a  secre- 
tion so  profuse,  a  great  mass  of  vascular  substance  is  required  ; 
and  the  consequence  of  permitting  a  gelatinous  collection  of 
matter  to  attain  to  such  a  size  is,  that  the  vessels  by  which  it  is 
secreted,  not  being,  as  in  a  case  of  suppuration,  ulcerated  or 
destroyed,  the  stool  or  basis,  consisting  of  those  vessels,  is  con- 
solidated into  a  tumour ;  there  is  a  sac  indeed,  which  may  be 
emptied,  but  there  is  also  a  stool  or  nucleus  to  that  sac  which, 
cannot  be  discussed,  which  indurates  more  and  more,  and  ac- 
tually increases  in  size  as  soon  as  the  sac  is  emptied,  and  the 
surface  exposed  to  ulceration :  thus  the  stool  of  a  fluid  tumour 
becomes  itself  a  solid  one  ;  and  I  have  seen  the  imprudent 
treatment  of  such  a  sac  establish  a  solid  tumour,  so  large  as  to 
impede  the  motions  of  the  jaw,  and  threaten  suffocation,  yet 
too  intimately  connected  with  the  great  vessels  and  nerves  to  be 
extirpated.  So  it  was  in  this  poor  woman ;  there  was  no  di- 
minution of  the  tumour,  not  even  a  temporary  relief  from  the 
suffocation,  though  the  matter  continued,  while  she  survived,  to 
run  from  the  opening,  thin  and  pellucid  like  saliva.  She  lay  re- 
clined, always  struggling  for  breath,  and  sometimes  attacked 
with  violent  asthmatic  paroxysms  ;  the  jaws  almost  entirely 
closed  ;  the  mouth  continually  open :  the  nostrils  dilated  ;  and 
the  stupor,  which  such  difficulty  of  breathing  causes,  increasing 
every  moment,  and  her  swallowing  being  equally  difficult  with 
hi-r  breathing,  she  expired  in  the  fourth  week." 

Timid  and  irresolute  sentiments  on  the  part  of  the  surgeon, 
often  bring  the  patient  into  those  desperate  circumstances:  one 
surgeon  confidently  and  sensiblv  advises  that  a  tumour  should 
be  unrelentingly  opened;  affirms  that  an  incision,  since  it  is  in- 
stantaneously performed,  cannot  be  much  more  painful  than  a 
puncture  which  is  but  a  momentary  pain,  and  protests  that,  by 
incision  is  the  only  way  in  which  the  sac  can  be  obliterated, 
and  a  tumour,  more  formidable  by  being  more  solid  than  the 
first,  prevented  from  growing  :  another  surgeon  contends,  that, 
in  a  sac  containing  merely  a  fluid,  a  puncture  will  suffice  ;  this 


Of  Salivary  Tumours*  529 

^pinion  is  too  flattering  to  the  little  fears  of  a  patient,  not  to  be 
received  ;  the  puncture  is  made,  and  the  patient  becomes  the 
more  credulous,  since  the  tumour  disappears  ;  but  it  returns 
again,  and  is  again  punctured,  till,  in  the  course  of  a  few 
months  of  expectation,  and,  after  various  trivial  operations  ot 
this  nature,  the  basis,  probably  the  body  of  the  gland  itself,  is 
hardened  into  a  solid  tumour,  and  then  not  even  that  operation, 
which  would  have  succeeded  at  first,  not  even  the  slitting  it 
open  and  ulcerating  with  escharotics,  whatever  surface  still  re- 
mains, will  prevent  its  continued  growth. 

Though  I  find  salivary  tumours  usually  filled  with  a  pellucid, 
gelatinous  fluid,  I  have  found  them  not  uufrequently  filled 
with  a  mixed  matter,  resembling  honey,  or  rather  resembling 
mustard,  and  consisting  of  a  tenacious,  gelatinous  matter,  mix- 
ed with  grains  and  lumps  of  a  bright  yellow  colour,  and  an  in 
tolerable  smell.  I  have  taken  notes  of  one  case  of  this  nature 
in  a  young  woman  from  Berwick,  whose  native  peculiarity  of 
accent,  had  got  a  singular  aggravation,  by  such  an  uncouth 
obliquity  and  imperfect  motion  of  the  tongue,  as  conveyed  the 
notion  of  her  attempting  to  chew,  and  turn  each  vocable  with 
her  tongue  before  she  proceeded  to  swallow  it,  in  place  of  ut- 
tering it.  This  was  produced  by  a  tumour  of  very  great  size, 
and  of  a  character  so  peculiar  as  plainly  to  denote  its  nature  :  it 
consisted  in  a  vast  collection  of  matter  in  the  sub-lingual  gland, 
and  as  that  gland  is  covered  by  the  whole  thickness  of  the  tongue 
within,  and  bv  the  mylo-hyoidei  muscles  without,  and  bound- 
ed by  the  line  of  the  jaw-bone,  it  had  the  following  singulari- 
ties of  character  :  it  could  not  be  distinguished  as  a  tumour, 
but  had  rather  the  appearance  of  a  general  swelling  of  the  lower 
part  of  the  face,  jaw,  and  neck,  such  as  often  accompanies  se- 
vere tooth-ach  or  mumps  :  upon  laying  the  hand  upon  the 
outside  of  the  neck,  below  the  lower  jaw-bone,  the  whole  hand 
was  filled  with  a  swelling,  apparently  solid,  but  so  little  convex 
or  circumscribed,  as  to  resemble  in  no  degree  the  tumour  of 
any  particular  gland  ;  and  yet  so  limited  and  so  firm,  as  not  at 
all  to  resemble  the  general  tumefaction  proceeding  from  tooth- 
ach.  Upon  introducing  the  finger  into  the  mouth,  you  found 
the  tongue  raised,  turned  edge-uppermost,  and  pressed  entire- 
ly towards  the  left  side  of  the  mouth,  the  external  tumour  beir:g 
in  the  right  side  ;  upon  pressing  the  fingers  very  firmly  down 
by  the  side  of  the  tongue,  and  re-acting  from  without,  you 
could  sensibly  perceive,  not  so  properly  a  fluctuation  as  an  elas- 
ticity, which  implied  the  presence  of  a  fluid  ;  the  tumour  seem- 
ed elastic,  like  a  foot-ball,  but  with  a  degree  of  tension  which 
made  it  seem  almost  solid.  It  was  by  comparing  a  variety  of 
'  ircumstances,  especially  the  original  place  and  slow  growth  of 

3   X 


530  Of  Salivary  Tumours. 

this  tumour,  that  I  confidently  referred  it  to  the  sub-linguai 
gland  ;  n  this  1  had  tht  advantage  ol  the  surgeon  under  whose 
particular  care  she  was,  but  I  did  him  the  justice  to  send  her 
back  to  him  again  and  again,  expr<  ssing  my  opinion,  and  my 
wish  at  the  same  time,  that  he  should  do  whatever  he  might 
imagine  right.  Bv  good  fortune  she  called  upon  me  the  day 
she  was  to  return  home,  nothing  bring  as  vet  done  to  the  tu- 
mour, but  supplied  with  abundance  of  blis,trrs  and  plasters  to 
apply  at  a  fit  opportunity  to  her  throat  :  I  felt  now  that  pro- 
fessional ceremonies  should  give  way  to  essential  charities  :  I 
placed  her  in  a  chair,  and  almost  without  her  consciousness,  at 
least  before  she  was  aware,  struck  a  fin.e  bleeding  lancet  deep 
into  the  tumour  by  the  side  of  the  fraenulum  linguae,  where, 
from  the  firm  compression  ol  the  surrounding  parts,  the  matter, 
though  too  gross  to  pass  freely  through  such  an  opening,  was 
spewed  out  from  the  orifice  in  a  manner  expressly  resembling 
that,  in  which  yellow  paint  is  squeezed  out  from  the  bladder 
upon  a  painter's  palette.  It  was  of  a  deep  saffron  colour,  thick- 
er than  mustard,  mixed  like  gruel  with  seed- like  particles,  and 
extremcU  fetid.  I  knew  that  the  tumour  was  not  emptied, 
though  the  outward  swelling  was  almost  gone  ;  but  I  also 
knew,  that,  even  though  I  should  not  enlarge  the  opening,  the 
second  secretion  from  the  surface  of  the  sac,  which  is  in  all  ca- 
ses thin,  would  dilute  and  wash  out  whatever  viscid  matter  re- 
mained ;  and,  when  she  saw  how  suddenly  mv  prognostic  was 
fulfilled,  she  expressed  a  perfect  confidence  in  whatever  1  pre- 
dicted, and  a  perfect  willingness  to  submit  cheerfully  to  what- 
ever I  proposed  to  do.  Next  day  I  introduced  the  point  of  the 
probe-bistoury  into  the  orifice  made  by  the.  lancet,  and  knowing 
that  the  lingual  artery  lies  on  a  lower  level,  imbedded  among 
the  muscles,  and  running  along  the  lower  surface  of  this  tu- 
mour, while  I  had  over  the  point  and  blade  of  my  bistoury 
nothing  but  the  inside  membrane  of  the  mouth  much  thicken- 
ed, I  ran  it  fearlessly,  and  at  one  stroke,  as  the  less  painful 
way,  along  the  whole  length  of  the  tumour,  when  the  thickest  of 
the  yellow  mucus  flowed  freely,  or  was  raked  out  with  the 
points  of  the  fingers,  and  the  handle  of  the  bistoury  ;  and  the 
tongue  descending  now  to  its  natural  level,  was  in  a  capacity 
once  more  of  delivering  the  peculiar  dialect  of  her  native  city 
in  all  its  purity. 

So  tense  and  apparently  solid  was  this  tumour,  in  conse- 
quence of  the  compression  of  so  many  surrounding  muscles, 
that  her  surgeon  mistook  it  for  a  solid  and  strumous  swelling. 
I  reckoned  that  in  this,  as  in  all  cases  of  sacculated  tumour, 
the  second  sreretion,  which  is  thinner,  would  wash  out  the 
thicker  mucus,  and  I  was  not  deceived,  but  she  left  me  too 


Of  Salivary  Tumours,  531 

early  for  me  to  witness  the  obliteration  of  this  sac.  I  find  it  in 
all  such  cases  a  matter  of  some  importance,  especially  in  a  girl 
to  anticipate  the  outward  suppuration  ot  any  sacculated  tumour 
by  puncturing  it,  though  to  a  great  depth  within  the  mouth 
and  under  the  tongue,  and  equally  necessary,  to  be  at  pains  in 
preserving  the  opening,  and  obliterating  the  sac  ;  a  slight  mis- 
conduct in  this  respect,  occasions  much  distress  to  the  patient 
and  much  superfluous  labour  to  the  surgeon ;  among  the  ex- 
amples of  this  which  I  have  had  occasion  to  remark,  the  fol- 
lowing is  the  most  instructive. 

"  Peggy  Hall  was  affected  with  a  tumour  which,  in  all  its 
stages,  and  for  a  course  of  three  years,  was  ill  understood,  and 
worse  treated:  it  was  of  a  great  size,  sacculated,  and  its  con- 
tents were  fluid.  She  was  a  stout  and  lusty  girl  about  twenty- 
two  years  of  age  ;  the  tumour  occupied  all  the  left  side  of  the 
neck,  from  the  lobe  of  the  ear  and  angle  of  the  jaw,  quite  to 
the  sternum,  displacing  the  mastoid  muscle.  This,  like  the 
tumour  of  Jenny  Urown,  arose  Irom  that  slight  inflammation, 
which  follows  the  extraction  of  a  tooth.  More  than  two  years 
ago,  after  being  distracted  with  tooth-ach,  she  had  two  cor- 
rupted teeth  pulled  from  the  lower  jaw,  and  she  distinctly  re- 
members, that,  two  days  alter  the  extraction  of  the  second 
tooth,  she  was  sensible,  upon  undoing  the  flannels  in  which 
her  swoln  and  inflamed  face  had  been  for  some  time  wrapped 
up,  that  there  was  a  little  lump,  about  the  size  of  a  small 
plumb  ;  it  lay  under  the  angle  ot  the  jaw,  and  has  never  ceased 
to  grow,  and  has  now,  without  the  slightest  pain  or  change  of 
colour,  attained  it  present  size. 

"  In  the  month  of  April,  1799,  she  was  directed  to  apply 
some  kind  of  plaster  ;  in  the  month  ot  May,  she  was  advised 
by  Dr.  Munro  to  have  it  opened  ;  in  a  few  weeks  after,  this 
was  attempted  by  the  surgeon  ol  the  village  in  which  she  lives, 
who  made  a  large  incision,  but  being  soon  alarmed,  he  laid 
aside  the  knife  and  lancet,  and  prosecuted  his  work  rather  by 
boring  than  by  cutting  ;  he  tried  with  probes  and  directories 
to  make  good  his  way  into  the  sac,  but,  having  pushed  them 
very  deep,  and  toiled  half  an  hour  in  vain,  he  abandoned  his 
purpose  :  the  scar  of  this  ill-concerted  operation,  remains  on 
the  face  of  the  tumour.  The  certain  conviction  that  a  respecta- 
ble surgeon  did,  three  months  before  we  saw  it,  dig  to  a  consid- 
erable depth,  without  finding  matter;  the  manifest  proof  of  his  . 
good  will  to  reach  it  in  this  large  scar  leit  after  his  operation, 
and  the  firm  adhesions  under  it  ol  the  skin  to  the  mastoid  mus- 
cle ;  the  difficulty  too,  of  distinguishing  fluctuation  in  a  very 
tense  sac,  made  more  tense  bv  the  general  construction  of  the 
platysma  myoides,  and  the  strong  pressure  of  the  great  mas- 


532  OfSa'nary  Tumours. 

toid  muscle,  was  enough  to  disconcert  us,  and  impress  a  be- 
lief that  this  tumour  could  not  be  of  a  fluid  nature,  and  indeed 
these  considerations  induced  almost  every  surgeon  who  had  a 
share  in  the  consultation  to  pronounce,  that  the  tumour  contain- 
ed no  matter,  and  should  not  be  punctured.  But  to  decide 
thus  is  to  forfeit  the  natural  advantages  of  our  own  skill,  and 
indeed  is  little  better  than  yielding  our  own  deliberate  judg- 
ment in  favour  of  the  opinion  of  a  man  plaiuly  ignorant  and  awk- 
ward :  so  far  from  trusting  any  thing  to  his  judgment,  or  believ 
ing  that  he  miscarried,  only  because  the  tumour  was  solid  and 
not  fluid,  I  think  it  no  difficult  mutter  to  demonstrate  the  kind 
of  awkwardness,  which  made  him  miscarry  in  his  operations. 

"  The  tumour  is  distinctly,  to  my  apprehension,  a  great  sac 
of  fluid  secretion :  there  is  nothing  doubtful  in  the  case  :  this 
sac  lies  under  the  platysma-myoides,  and  undt  r  and  before  the 
mastoid  muscle  ;  the  belly  of  the  mastoid,  being  raised  upon 
the  bag  or  tumour,  feels  soft  and  flaccid,  and  might  have  seem- 
ed to  an  unskilful  surgeon,  to  form  a  part  of  the  tumour  ;  by 
making  his  incisions  over  the  belly  of  the  muscle,  he  could  not 
penetrate  to  the  sac  otherwise  than  through  the  body  of  jtfie 
mastoid  muscle  ;  having  cut  to  a  considerable  depth  among  so 
lid  and  quivering  flesh,  he  became  alarmed  ;  willing  still  to 
penetrate  farther,  and  yet  without  danger,  he  bored  with  his  fin- 
ger, cut  a  little  obliquely  with  his  knife,  and  bored  a  little  more 
with  his  directory,  till  having  buried  it  apparently  in  the  tu- 
mour to  the  depth  of  three  or  four  inches,  he  believed,  and  to 
the  ignorant  relations  and  patient,  seemed  to  prove,  that  there 
was  no  fluid  in  the  tumour,  while  there  was  nothing  singular  in 
all  this  but  his  own  awkwardness  :  he  had  penetrated  entirely 
under  the  belly  of  the  mastoid  muscle,  pushing  his  probes 
obliquely  betwixt  it  and  the  sac  ;  to  avoid  the  great  vessels  of 
the  neck,  he  wrought  obliquely  backwards :  by  cutting  oblique- 
ly backwards,  he  made  good  his  way  under  the  belly  of  the 
mastoid  muscle.  The  young  woman  endured  the  disappoint- 
ment, and  suffered  the  tumour  still  to  extend,  not  without 
great  inconvenience  and  deformity  for  seven  or  eight  months : 
the  operation  being  then  performed  more  correctly  and  confi- 
dently, every  circumstance  tended  to  confirm  the  notions  I  had 
formed  of  this  awkward  proceeding  :  the  surgeon  who  now 
operated  was  timid  in  his  manner  of  performing  the  operation 
and  careless  in  conducting  the  cure.  The  incision  through  the 
skin  only  was  freely  made  ;  the  incisions  through  the  platysma- 
myoides  were  made  timidly,  the  flesh  of  its  fibres  retracting 
and  quivering  as  they  were  cut  :  the  sac  then  burst  from  be- 
twixt the  divided  fibres  of  the  muscle,  white  and  transparant. 
I  could  almost  distinguish  the  fluid  through  it  ;   and  this  hy- 


Of  Salivary  Tumours.  533 

drocele-like  sac  being  cut,  several  pounds  of  thin  serous  fluid 
gushed  out :  then  the  long  iron  probe  was  passed  across  the 
cavity  of  the  tumour,  and  its  point  cut  upon  at  the  anterio: 
edge  of  the  mastoid  muscle  ;  in  short,  near  the  place  of  the 
former  incisions :  whereas,  to  lie  across  the  tumour,  the  point 
should  have  been  cut  out  behind  the  belly  of  the  mastoid,  and 
then  the  seton  or  cord  would  have  more  effectually  inflamed  the 
sac,  and  obliterated  the  cavity. 

If  these  sacculated  and  solid  tumours  of  the  neck  and  jaws 
are  interesting  from  their  frequency,  there  are  others  still  more 
so  from  their  danger:  they  are  carefully  to  be  distinguished 
from  other  tumours,  especially  from  those  of  an  aneurisma! 
and  varicose  nature ;  and  I  especially  request  you  to  remem- 
ber, that,  of  the  tumours  which  occupy  the  fore-part  of  the 
trachea,  and  are  connected  with  the  vascular  system  of  the  thy- 
roid gland,  a  great  proportion  are  venous :  aneurism  of  the 
carotid  artery  is  indeed  so  rare  a  disease,  that  it  is  not  certainly- 
known  whether  such  a  disease  exists,  it  absolutely  is  not  under- 
stood how  or  from  what  causes  the  patient  dies.* 

The  profuse  plexus  of  inosculating  veins  about  the  angle  of 
the  jaw,  and  the  corresponding  branches  of  the  maxillary  and 
facial  arteries,  are  frequently  thus  diseased,  and  still  more  fre- 
quently the  veins  and  arteries  of  the  thyroid  gland,  whose 
trunks,  as  they  run  down  the  fore-part  of  the  neck,  are  dilated, 
and  form  a  conspicuous  part  of  the  tumour.  Jean  Bryce  has 
a  tumour  of  this  nature,  growing  from  her  early  years,  which, 
like  those  occurring  in  the  skin,  the  lip,  the  eye-lids,  the  rec- 
tum, &c.  began  in  a  very  small  tumour,  having  nothing  pecu- 
liar in  its  form :  it  began  when  she  was  a  little  girl,  has  been 
waxing  gradually  larger  for  these  thirteen  years,  and  seems  tc 
me  almost  purely  an  enlargement  of  the  vessels  and  cellular 
substance  of  the  thyroid  gland.  It  is  difficult,  in  describing 
such  a  tumour,  to  distinguish  the  sensations  conveyed  by  the 
touch  and  by  the  eye,  from  those  conjectures  which  imagina- 
tion presents  to  us  in  handling  the  tumour.     The  marks  I  have 

•  I  faw  a  young  woman,  not  44  years  of  age,  die  of  this  difeafc,  in  the  Cxth- 
weck  after  the  dilatation  of  the  artery  began.  She  had  a  cough  and  quickened 
pulfe,  and  her  diforder  was  miftaken  for  a  cold  :  fhe  had  great  difficulty  of  fwal- 
lowing,  and  it  was  miftaken  for  the  effect  of  fore  throat  and  fwelliiig  of  thi 
glands :  fhe  had  a  conltant  ftupor,  and  it  was  afcribed  to  fever  :  but  the  ccm- 
preffion  of  fo  large  a  tumour,  lodged  clofe  upon  the  trachea,  and  braced  down 
upon  it  by  all  the  ftrong  mufcles  of  the  throat,  and  compreffed  too  by  the  jaw- 
hone,  could  not  fail  to  excite  at  once  difficult  deglutition,  dyfpncea,  and  ftupor,  and 
thefe  were  the  fymptoros  of  which  fhe  died.f 

f  There  is  now  at  lead  no  doubt  of  the  exiflenee  of  this  difeafc  :  Mr.  Aft'?} 
Cooper  has  operated  twice  for  it,  once  with  complete  fuccefs,  in  tr-e  other  cafe  the 
patient  died,  bot  not  from  the  operation.     S. 


5M>  Of  Salivary   Tumour,. 

taken  in  my  case-book  are  of  a  mixed  nature  ;  they  are  these  ; 
the  tumour  was  in  its  early  stage  small,  knuckle-like,  but  soft, 
round,  moveable,  and  without  pulsation  :  whatever  its  nature 
may  have  been  at  the  first,  the  structure  of  the  part  is  now  en- 
tirely changed  ;  the  tumour  is  now  large,  soft,  spongy,  and 
spreads  equally  on  each  side  of  the  throat,  filling  the  whole 
neck,  and  occupying  expressly  the  place  of  the  thyroid  gland  : 
though  soft,  it  rolls  loose  under  the  skin,  is  moveable  also  in 
respect  to  the  muscles  and  internal  parts,  and  may,  on  each 
side,  be  worked  backwards  under  the  mastoid  muscle,  especi- 
ally towards  the  right  side  of  the  neck,  where  the  tumour 
seems  more  condensed  :  it  suffers  a  general  subsultus,  or  shock, 
from  each  stroke  of  the  carotid  arteries,  but  it  has  also  a  particu- 
lar and  distinct  pulsation  within  itself,  which,  though  never  in* 
termitted,  is  yet  more  sensibly  felt  when  the  blood  contained 
within  it  is  repressed  through  the  veins  into  the  general  course 
of  the  circulation ;  for,  while  the  cells  of  the  tumour  fill  again, 
the  blood  seems,  at  first,  to  ooze  or  pour  insensibly  into  the  tu- 
mour, but,  when  it  is  a  little  filled,  the  stroke  of  the  arteries 
which  are  filling  it  begins  to  be  felt,  and,  as  it  fills,  the  pulsation 
strengthens  still,  being  completely  injected  and  beepme  tense, 
there  is  a  deep  and  stroma  throbbing  in  every  part  of  the  mass : 
in  this  particular  case,  there  is  much  accumulation  of  solid  mat- 
ter, i.  e.  of  thickened  vessels  and  cellular  substance,  besides 
the  mass  of  circulating  blood  :  the  proportion  of  both  can  be 
distinctlv  perceived,  for,  by  handling,  and  squeezing  the  tu- 
mour, and  repressing  the  blood,  it  can  be  so  much  of  it  re- 
pressed into  the  veins,  as  to  diminish  its  size  by  two  thirds ; 
but  no  force  can  repress  it  entirely,  as  in  smaller  tumours,  or 
in  varicose  aneurisms.  When  the  blood  is  repressed,  the  loose 
doughy  feeling  of  cellular  substance  and  dilated  veins  is  more 
sensibly  felt,  and  is  perceived  to  form  the  chief  mass,  and  es- 
pecially the  basis  of  the  tumour  :  when  the  blo<\d  is  thus  re- 
pressed, you  can  distinguish,  by  pinching  strongly,  a  thick  and 
solid  sac  within  the  skin,  and  quite  unconnected  with  it.  Be- 
sides the  other  intimations  of  its  connection  with  the  thvroid 
gland,  and  the  whole  vessels  and  substance  of  the  throat,  I  can 
plainly  distinguish  the  thyroid  arteries  running  long  and  tortu- 
ous over  the  sides  of  the  tumour*  as  if  they  descended  from 
under  the  chin,  and  then  spread  over  the  sac,  (so  far  are  these 
arteries  displaced  from  their  natural  course)  they  divide,  upon 
the  surface  of  the  tumour,  into  lesser,  yet  very  perceptible 
twigs,  then  dive  into  its  substance,  and  lose  themselves  :  while 

*  The  thyroid  arteries  were,  even  in  their  letter  branches,  dilated  to  the  fize  of 
'he  temporal  arceries. 


Of  Salivary  Tumours,  535  • 

the  external  jugular  veins,  dilated  both  in  their  trunks  and 
branches,  run  tortuous  over  its  surface,  especially  down  the 
middle  of  the  neck. 

The  whole  tumour,  when  voided  of  blood  by  continued  pres- 
sure, has  the  puffy  feeling  of  varicose  and  dilated  veins  ;  when 
distended  by  the  reflux  of  blood,  it  has  the  firm  elasticity  of  a 
sac  full  of  some  fluid,  dense  as  the  blood  is,  and  having  firm 
and  fleshy  walls. 

These  are  the  characters  of  a  tumour  which  is  to  be  avoided 
am  where,  but  in  the  neck  most  of  all  :  which  might  indeed 
have  been  extirpated  in  its  early  growth  when  circumscribed, 
small,  soft,  and  not  pulsating,  by  laying  open  this  part  of  the 
neck  fairly,  by  dissecting  cautiously  round  the  tumour,  and 
tying  its  root;  but  now  the  disease  has,  by  carrying  the  dila- 
tation of  veins,  arteries,  and  cellular  substance,  deep  inco  the 
substance  of  the  neck,  become  too  formidable  to  be  dissected 
out.  The  laying  open  the  neck  for  the  extirpation  of  so  slender 
a  tumour  in  a  little  girl  of  ten  years  of  age,  must  have  seemed 
harsh  to  parents,  had  it  been  proposed  ;  but  how  just  the  prog- 
nostic of  the  surgeon  is,  when  he  advises  such  an  operation, 
never  is  known  till  vears  have  elapsed,  and  the  case  is  despe- 
rate. This  girl,  after  enjoying  a  respite,  not  without  frequent 
alarms,  is  doomed,  in  a  few  years  hence,  to  feel  the  conse- 
quences of  neglecting  such  a  tumour  in  its  early  stage  :  the 
disease  tends,  according  to  my  apprehension,  to  spread  in- 
wardly, and  the  first  haemorrhages  will  be  into  the  trachea  or 
throat.* 

In  another  case  the  form  of  the  tumour  was  still  more  cir- 
cumscribed, and  corresponded  more  perfectly  with  the  de- 
scription formerly  given  of  this  disease  ;  it  is  similar  to  the 
preceding  case  in  having  begun  from  the  girl's  early  vears,  and 
increased  till  now  that  she  seems  about  28  years  of  age  ;  in 
having  a  lively  and  strong  pulsation  ;  in  having  a  thick  and 
spongy  basis,  seated  on  the  jaw  bone,  extending  into  the  sub- 
stance of  the  cheek,  and  over  the  chin  into  the  substance  of  the 
neck  and  throat ;  in  having  this  stool  or  basis  less  compressi- 
ble, yet  plainly  filled  with  circulating  blood,  while  the  central 
parts  of  the  tumour  are  more  distinctly  sacculated;  consisting 
of  a  wider  spongy  substance  of  large  cells,  or  of  something 
like  a  proper  sac,  from  which  the  blood  can  be  entirely  squeez- 
ed out  by  pressure.     But  it  differs  in  being  superficial,  in  be- 

*  The  thyroid  gland  has  been  fuceefsfully  extirpated  by  Default.  In  doing  if 
which  is  exceedingly  difficult,  and  fhould  not  be  attempted,  except  by  a  moft  ac- 
curate anatomift,  and  dexterous  and  intrepid  operator,  the  four  thyroideal  arterie* 
niuft  be  tied  before  they  are  cut,  and  the  principal  part  of  the  diffeiftion  nuii> 
he  done  with  the  handle  of  the  fcalpck     S>. 


536  Of  Salivary  Tumours. 

ing  cutaneous,  or. almost  so,  in  having  thin  walls,  and  a  red 
colour,  deepening  into  a  purple  at  those  points  from  which  the 
blood  bursts  out :  large  dilated  veins,  two  or  three  especially- 
like  venous  trunks,  descended  from  the  central  parts  of  the 
tumour,  into  the  veins  of  the  neck,  while  the  thick  and  fleshy 
basis  of  this  tumour  so  encircles  the  jaw-bone,  enters  so  deeply 
into  the  substance  of  the  cheek,  and  joins  so  solidly  the  neck 
to  the  jaw-bone,  that,  though  this  girl's  life  were  the  most  va- 
luable, (she  is  like  many  I  have  observed  who  have  these  im- 
perfections, an  idiot)  and  her  circumstances  the  most  despe- 
rate, I  hardly  know  how  it  could  be  extirpated,  since  there  is 
no  way  of  effectually  extirpating  such  tumours  but  by  leaving 
not  the  slightest  part  of  the  diseased  substance  behind. 

But  pulsation  is  not  an  essential,  nor  inseparable  character- 
istic of  such  tumours,  and  it  is  my  duty  both  to  give  you  no- 
tice of  this  fact,  and  to  acknowledge,  with  that  generous  tem- 
per which  becomes  one  discoursing  on  matters  of  life  and  death, 
whatever  errors  or  mistakes  I  recollect  in  my  own  opinions  or 
practice.  I  was  consulted  for  a  tumour  of  this  kind  in  a  young 
woman  (also  an  idiot)  about  24  years  of  age,  big,  lusty,  and 
otherwise  in  perfect  health ;  but  being  accompanied  by  no 
friends,  I  could  learn  nothing  of  the  history  of  her  disease. 
Her  neck  was  fleshy  and  fat,  her  cheek  round  and  full,  her 
features  large  and  masculine,  and,  behind  the  angle  of  the  jaw, 
was  seated  a  tumour  of  this  singular  character:  the  skin  was 
thick  and  sound,  and  altogether  unconnected  with  the  tumour  ; 
the  tumour  was  conical,  and  occupied  exactly  the  triangular 
hollow  behind  the  corner  of  the  jaw,  but  it  was  a  tumour  which 
we  could  not  say  it  was  either  very  soft,  or  very  elastic,  reced- 
ed like  a  loose,  puffy,  and  unconstricted  hernia,  upon  the  slightest 
pressure :  when  it  receded,  you  could  pinch  up  a  distinct  and 
thick  sac,  which  held  not  the  slightest  communion  with  the 
skin,  or  its  system  of  vessels  :  the  contents  of  this  sac  could 
be  almost  dissipated  by  pressure,  and  no  solid  nor  spongy  basis 
could  be  felt  at  the  deepest  part  of  this  sac,  nor  could  the  slight- 
est degree  of  pulsation,  or  whizzing  noise  be  perceived,  when 
the  fluid  returned  into  the  sac.  The  case  so  entirely  resembled 
that  of  Peggy  Hall,  viz.  a  seemingly  thin  and  serous  matter, 
contained  within  a  large  and  flaccid  sac,  that  I  entirely  believed 
so.  Although  the  characteristic  of  the  almost  total  receding  of 
the  fluid  was  too  marked,  and  particular,  not  to  have  excited 
strong  suspicions ;  yet,  in  opposition  to  Mr.  Russel,  and  seve- 
ral respectable  and  judicious  surgeons,  I  believed  that  it  con- 
tained matter,  and  was  confident,  at  all  events,  that  there  was 
no  shadow  of  danger  in  making  the  experiment  of  puncturing 
the  tumour  j  in  opposition  to  their  better  judgment,  I  made  a 


Of  ■  Salivary  Tumours.  537 

slight  incision  through  the  skin,  and,  with  the  point  of  a  bleed- 
ing-lancet, punctured  the  sac,  and  found  that  it  contained  actu- 
ally blood,  which  seemed  to  ooze  out  into  the  sac,  from  innu- 
merable small  vessels,  had  no  arterial  pulsation,  and  no  dis- 
tinct character  by  colour  or  otherwise  of  being  venous  or  arte- 
rial blood  ;  it  had  so  little  impulse,  as  to  make  not  the  slightest 
sugillation  of  the  neck,  at  the  place  where  the  puncture  was 
made,  and  healed  like  a  vein  opened  in  bleeding.  I  take  a 
pleasure  in  mentioning  this,  both  as  it  ascertains  that  often  the 
sac  is  of  great  extent,  and  the  transit  of  the  blood  from  the  • 
arteries  to  the  veins  through  the  cells  very  slow  ;  that  the  tu- 
mour may  be  large,  and  truly  an  aneurism  from  anastomosis, 
without  being  characterized  by  pulsation  ;  and  also  as  this  lit- 
tle narrative  may  prove  a  warning  to  you,  for  the  b'.ood  might 
have  been  difficult  to  restrain,  and  the  wound  difficult  to  heal. 

As  I  always  reckon  a  case  more  useful  in  proportion  as  it 
approaches  the  more  ordinary  occurrences  of  practice,  and 
sacculated  tumours  on  the  throat  containing  blood  are  so  fre- 
quent, and  require  such  careful  treatment,  that  I  will  occupy 
a  small  portion  of  your  time  in  laving  an  example  before  you. 

Miss  A  came  from  a  distant  part  of  the  country,  with 

a  tumour  encircling  the  whole  throat,  from  car  to  ear  almost, 
and  extending  from  the  chin  to  the  sternum.  This  tumour, 
the  growth  of  several  years,  could  not  be  a  suppuration  of  the 
thyroid  gland,  for  there  had  been  from  the  first  no  induration 
nor  inflammation,  but  a  sac  containing  a  secreted  fluid,  in- 
creasing slowly  in  quantity,  till  the  tumour  covered  all  the 
trachea.  This,  like  every  other  great  sac,  was  far  from  being 
tense,  it  could  be  pinched  up  with  the  finger  and  thumb,  so  as 
to  make  the  uncommon  thickness  of  the  sac  very  sensible  to 
the  feeling,  and  the  fluid  so  distinctly  fluctuated,  and  so  easily 
from  side  to  side  of  the  tumour,  as  to  convey  the  impression 
of  its  being  like  that  of  Peggy  Hall,  of  a  thin  and  serous  na- 
ture ;  nor  was  there  any  other  reason,  except  the  peculiar  seat 
of  the  tumour,  to  doubt  of  its  being  serum,  or  to  apprehend 
that  a  tumour  so  old,  and  forming  so  slowly,  could  contain 
blood. 

In  the  choice  of  means  for  obliterating  so  large  a  sac,  occu- 
pying in  a  young  lady  the  whole  circle  of  the  throat,  it  is  most 
natural  to  incline  to  those  methods,  which,  if  successful,  are 
least  liable  to  produce  either  a  scar,  or  unsightly  thickening;,  or 
any  other  deformity  :  but,  in  the  present  case,  I  could  not  but 
prefer  the  most  decisive  method  of  proceeding,  to  those  which 
seemed  milder,  for  the  following  reasons.  The  flaccid  state 
of  the  tumour  was  such  as  permitted  me  easily  to  pinch  up 
the  sac,  and  feel  most  sensibly  that  its  walls  were  peculiarly 

3  Y 


538  Of  Salivary  Tumours. 

thick  and  fleshy  :  I  foresaw  that  if  such  means  only  were  re- 
sorted to  as  tend  to  obliterate  the  sac  slowh ,  and  by  successive 
paroxvsms  of  inflammation,  the  muscular  fascia  oi  the  neck, 
the  platvsma-myoides,  would  be  united  by  adhesion  to  this 
thick  and  fleshv  sac  :  I  feared  that  if  the  walls  thus  constituted 
were  kept  long  in  an  inflamed  state,  irritated,  and  thickening, 
the  thyroid  g'and  would  not  entirely  escape,  but  become  in- 
flamed and  hard,  so  as  to  form  a  solid  basis  for  the  tumour  ; 
and  I  could  not  but  recollect  how  much  more  apt  the  thvroid 
gland  is  to  swell  in  the  female  sex  :  for  these  and  various  rea- 
sons, especially  from  my  patient's  intention  of  re  turning  home, 
I  proposed  that  method  which,  though  it  may  be  blamed  as  the 
most  cruel,  is  often  in  truth  the  most  lenient,  by  being  the  most 
effectual;  I  mean  the  passing  a  seton  or  syndon  across  the  sac: 
but,  from  that  timidity  which  carries  with  it  such  strong  apolo- 
gies, the  method  I  proposed  was  unfortunately  declined,  and 
that  of  a  simple  puncture  preferred. 

Having  called  Dr.  Monro  into  consultation,  the  propriety  of 
opening  the  sac  was  decided  on,  from  thtse  motives  ;  first,  the 
certainty  of  the  sac  continually  increasing  in  size,  deforming 
the  neck  more  and  more,  and,  perhaps  in  the  end,  corrupting 
the  cartilages  of  the  larynx,  and  making  its  way  into  the  tra- 
chea, and  forming  there  such  irregular  suppurations,  and  incu- 
rable fistulas,  as  often  prove  fatal.  Secondly,  that  there  is  no 
kind  of  motive  for  refraining  from  this  very  necessary  act  of 
duty,  since  the  fluctuation  is  distinct,  the  sac  circumscribed, 
the  fluid  not  repressible  ;  no  varicose  veins  occupying  its  sur- 
face, no  pulsation  felt  from  within  its  substance,  to  make  us 
fear  its  being  supplied  by  any  remarkable  arteries. 

It  appeared  to  ue  that,  if  there  was  blood  in  the  tumour,  or 
haemorrhagv  in  the  operation,  it  could  be  only  such  as  might 
distil'  gradually  from  the  surface  of  so  firm  a  sac,  not  such  ac- 
tive hiemonhagy  as  might  endanger  life,  or  prevent  the  suppu- 
ration of  the  cavity.'* 

Upon  making  an  incision  through  the  skin  and  fascia  of  the 
lower  part  of  the  neck,  and  striking  the  lancet  directly  into  the 
tumour,  a  thin  bloody  serum  ran  out,  or  rather  pure  blood,  for 
it  coagulated  in  the  saucers,  even  before  it  could  be  turned 
from  them  into  the  basin  :  it  expresslv  resembled  that  thin 
bloody  secretion,  which  I  have  so  often  seen  run  out  upon 
making  openings  round  the  knee-joint,  or  in  swell  ngs  when, 
in  consequence  of  a  shock  or  rude  blow,  blood  of  this  dilute 


*  The  opinion  zud  descriptions  arc  extracted  from  my  cafc-bonl: ;  the  other  cir- 
cumltances  of  the  cafe  are  not  from  recollection,  which  I  never  truft  to,  but  from 
letters  and  memorandums. 


Of  Salivary  Tumours.  539 

and  serous  nature  is  effused,  as  from  the  shock  of  riding  against 
the  pole  of  a  carriage,  &cc.  or  in  consequence  of  high  and  sud- 
den inflammation  ;  c\in  alter  strains  oi  the  muscles  without 
any  external  injury,  I  have  seen  such  tffasions  of  blood,  and 
shall  have  occasion  to  relate  some  fatal  cases  of  this  nature. 

In  the  evening  when  the  plug  was  withdrawn,  the  same  thin 
bloody  serum,  ihstantan  lating,  flowed  from  the  sac; 

and  at  each  dressing,  during  the  first  four  days,  the  fluid  which 
was  discharged  seemed  little  different  from  pure  blood;  it  was 
plainly  a  sort  of  secretion  from  the  thick  walls  ol  the  tumour, 
it  gradual!)  became  less  coagulahle,  then  verj  ash, 

and  ripened  before  the  tenth  dav  into  pure  and  well  conditioned 
pus,  importing,  that  the  internal  surface^of  the  sac  was  in  a 
state  of  suppuration,  and  inclined  to  heal. 

Now  the  time  of  mv  patient's  departure  approached,  and  the 
seton  or  long  skein  of  co:ton  by  which  the  sac  was  to  be  kept 
inflamed  till  obliterated,  and  the  sponge  with  which  the  opening 
was  to  be  preserved,  had  been  long  used,  and  those  who  were 
in  future  to  manage  them  made  familiar  with  their  use.  The 
former  was  lodged  deep,  and  within  the  sac  by  the  long  probe  ; 
and  the  latter  had  betn  gradually  enlarged  so  as  rather  to  dilate 
the  opening  in  proportion  as  the  cavity  of  the  sac  lessened  ;  the 
Gentleman  who  was  to  be  intrusted  with  this  part  of  the  pro- 
cess was  a  party  at  each  dressing,  and  I  had  r.o  fear  that  all 
would  go  well  :  but  my  first  letter  from  the  country  announced 
that  the  .matter  was  foul,  blood}',  and  fetid  ;  the  flow  of  it  ob- 
structed by  fungus,  almost  the  orifice  ;  that  the  intro- 
duction of  the  sponge  was  become  difficult,  or  almost  impossi- 
ble ;  and  that  advice  was  expected  of  me,  which  really  could 
be  of  no  avail  without  either  my  personaTpresence,  or  my  pa- 
tient returning  to  town.  I  was  sensible  that  now  the  means  I 
recommended  must  be  resorted  to,  lor,  (although  it  was  not 
included  in  the  description  of  all  that  was  wrong,)  I  was  sensi- 
ble that  there  must  be  a  great  thickening  of  the  neck  and  throat, 
from  the  induration  of  the  sac:  I  found  that  much  pressure  and 
thum  >ing  of  the  parts  was  necessary  to  discharge  the  matter, 
and  that  she  had  suffered  from  attacks  of  fever,  accompanied 
with  pain  and  swelling  of  the  tumour. 

By  good  fortune  I  was  called  into  that  part  of  the  country, 
and  found  when  I  visited  this  ladv,  the  whole  tumour  condens- 
ed into  a  thick  spongy  mass,  inflamed  over  the  whole  surface, 
and  spongy  in  its  substance,  in  consequence  of  continual  tortur- 
ing and  squeezing,  while  pieces  of  the  sponge  tent  were  sus- 
pected to  lie  buried  in  it  :  I  actually  encountered  these  lost  pie- 
ces of  sponge  with  the  probe,  and  hooked  them  out  :  enlarged 
the  lower  opening,  passed  the  long  iron  probe  obliquely  across 


540  Of  Salivary  Tumours. 

the  throat  to  the  upper  part  of  the  tumour,  and  examined  how 
I  might  best  cut  it  out:  but  this  I  found  a  more  difficult  and 
delicate  operation  than  I  had  imagined,  for  the  upper  part  of 
the  sac  lay  under  the  left  lobe  of  the  thyroid  gland,  entirely  un- 
der it,  so  that  a  considerable  thickness  of  parts  was  interposed 
betwixt  the  probe  and  the  skin,  and  it  seemed  impossible  to  cut 
out  the  probe  without  wounding  the  thyroid  gland  and  some  of 
its  arteries.  The  best  I  could  hope  was  by  circumspection  not 
to  cut  a  large  one,  I  therefore  felt  long  and  circumspectly 
round  ihe  point  of  the  probe,  made  an  incision  through  the 
skin  onlv,  such  as  admitted  the  point  of  my  finger,  and  with 
that  feeling  the  mass  of  the  thyroid  gland,  and  being  sensible 
that  no  large  artery  was  under  my  finger,  I  dissected  through 
it.  The  bleeding  was  so  violent  and  alarming  that  my  assist- 
ant, a  medical  Gentleman  inured  for  forty  years  to  all  variety 
ol  practice,  tainted,  and  forsook  me.  I  could  not  go  on  to  open 
the  sac,  for  that  would  have  left  me  without  any  surface  to 
press  against,  or  cut  upon,  if  I  should  need  to  open  the  skin 
mure  widely,  and  take  up  an  artery  ;  and  had  I  opened  the  sac, 
the  blood  would  have  been  admitted  to  its  cavity  :  laying 
therefore  a  piece  of  sponge  into  the  incision,  and  pressing  it 
down  with  the  thumb,  I  allowed  some  time  to  elapse,  and  the 
hsemorrhagy  ceased,  so  that  I  was  enabled,  in  half  an  hour,  to 
proceed  and  cut  out  the  probe  :  having  passed  it  I  drew  a  coarse 
big  seton  across  the  sac,  and  left  it  there  with  careful  instruc- 
tions how  to  use  it,  viz.  by  carefully  shifting  and  replacing  the 
cord  ;  by  applying  poultices  outwardly,  and  slightly  astringent 
injections  inwardly,  according  to  the  state  of  the  parts  :  thus 
from  a  mistaken  lenity  the  cruelty  was  still  to  do,  and  the 
thickening  and  deformity  fixed  and  irremediable. 

Recollect  then  in  your  future  practice,  that  a  tumour  hard  at 
first,  and  gradually  softening  into  fluctuation,  must  contain  mat- 
ter more  or  less  mature;  but  that  a  tumour  soft,  even  when  ve- 
ry small,  gradually  enlarging,  and  having  no  stool,  or  basis,  may 
contain  blood  :  that  a  tumour  of  this  last  description,  seated  on 
the  fore-part  of  the  neck,  often  does  contain  blood,  though  it 
is  neither  varicose,  nor  pulsating  :  beware  then  to  make  no 
rash  opening  without  making  this  prognostic,  that  the  tumour 
may  contain  blood  not  matter. 

Believe  me,  gentlemen,  I  am  incapable  of  magnifying  by 
the  manner  of  my  narrative  any  such  trivial  difficulties,  as  this 
of  the  thyroid  gland  and  its  system  of  vessels,  being  interposed 
betwixt  the  kniie  and  the  probe  ;  I  mention  these  occurrences 
as  lessons  concerning  little  points  of  practice,  which,  without 
experience,  ycu  could  never  learn,  and  which  indeed  without 
careful  notes  of  the  trivial  perplexities  of  the  hour  of  visit,  I 
should  not  have  remembered  to  teach  you. 


Of  Salivary  Tumours.  541 

But  to  return  to  subjects  still  more  interesting :  you  will  have 
observed  that  I  speak  ot  erosion  and  caries  of  the  cartilages  of* 
the  larynx,  as  producing  very  dismal  consequences,  and  as  far 
from  being  unlrequent,  and  that  I  allude  to  the  possibility  of 
blood  or  matter  penetrating  through  the  walls  ot  a  suppurating 
or  sacculated  tumour  into  the  throat ;  and  when  this  happens, 
the  complicated  iuiutsons  ot  the  throat,  in  breathing,  swallow- 
ing, and  speaking,  produce  a  strange  variety  of  suffering.  I 
have  remarked  in  practice  several  6tages  of  danger  and  suffer- 
ing, which  I  think  it  desirable  you  should  be  acquainted  with  : 
first,  the  suppuration  which  I  am  now  going  to  describe,  seems 
to  me  ot  a  scrophulous  nature  ;  it  begins  without  any  sensible 
inflammation,  it  ripens  insensibly,  and  extends,  and  displaces  the 
trachea,  and  oesophagus,  without  pain  or  any  other  disorder, 
except  difficulty  of  deglutition  ;  it  grows  so  very  slowly,  that 
the  patient  is  no  way  alarmed,  and  the  surgeon  is  not  at  first 
conscious  of  all  the  dangers  of  his  situation.  When  first  the 
suigeon's  attention  is  called  to  the  tumour,  it  has  very  general- 
ly attained  to  a  great  size,  at  once  compressing  the  throat,  and 
bulging  out  the  neck  :  a  diffused  tumour  is  observed  towards 
the  lower  part  of  the  neck,  below  the  place  of  the  larynx,  ap- 
proaching nearer  to  the  clavicle  than  the  throat,  occupying  the 
interstices  ot  the  muscles,  and  capable,  like  a  hernia,  of  being 
repressed  behind  the  mastoid:  the  fluctuation  of  the  matter  is 
obscure,  when  the  surgeon  feels  for  it  it  in  the  neck  only  ;  but 
when  he  looks  into  the  throat,  he  distinctlv  perceives  a  soft, 
uniform  tumour,  pressing  the  tonsil  and  root  of  the  tongue  to- 
wards the  opposite  side,  intruding  upon  the  throat,  obstructing 
the  breathing  much,  but  still  more  the  deglutition :  he  ;s  sensi- 
ble that  this  is  the  upper  part  of  that  sac,  which  protrudes 
in  the  neck  below  ;  by  pushing  his  fingers  into  that  side  of  the 
throat,  he  teels  the  softness  and  fluctuation  of  the  matter  con- 
tained within  a  large  and  flaccid  sac ;  and  by  tapping  below, 
and  feeling  or  looking  at  the  same  time  into  the  throat,  he  is 
sensible  that  it  is  one  great  abscess  occupying  all  the  neck,  King 
deep  under  the  muscles,  in  the  direction  of  the  oesophagus,  and 
what  is  more  dangerous  still,  of  the  trachea;  and,  it  he  is  as 
conscious  as  he  should  be  of  this  danger,  and  as  clear  as  these 
signs  should  make  him  of  the  extent  and  place  of  the  abscess, 
he  with  his  scalpel  cuts  through  the  skin  in  the  lower  part  of 
the  neck,  dissects  till  he  feels  distinctly  the  sac  and  the  fluctua- 
tion, and  then  plunging  his  knife  or  lancet  into  it,  prevents  the 
sad  consequences  of  its  bursting  into  the  throat,  by  this  timelv 
opening  in  a  dependent  point ;  by  the  pressure  of  the  muscles, 
which,  every  time  they  turn  the  neck,  or  move  the  throat,  press 
the  sides  of  the  sac  in  contact,  it  is  obliterated  though  slowly, 


542  Of  Salivary  Tumours. 

and  the  judicious  use  of  injections  and  of  syndons  contributes 
*  greatly  to  the  cure.  I  have  more  than  once  seen  the  throat 
surrounded  on  every  side  with  these  baggy  abscesses,  occupy- 
ing the  space  under  the  angle  of  the  jaw,  and  the  two  sides  of 
the  neck  irregularly,  so  as  to  require  incisions  which  it  yet  is 
always  unpleasant  to  make:  nor  should  the  surgeon  ever  allow 
himself  to  make  such  incisions  without  tha.t  declaration,  which 
may  be  so  necessary  to  his  own  good  repute,  viz.  that  it  is  not 
impossible  the  tumour  may  already  have  communication  with 
the  trachea,  or  that  air  may  issue  along  with  the  matter  ;  for  of- 
ten the  abscess  bursts  in  the  throat  with  an  opening  so  small, 
and  oi  so  valvular  a  form,  that  the  abscess  imperfectly  dischar- 
ged of  its  contents,  maintains  its  original  form  and  size,  while 
the  slow  issue  of  the  matter  from  it  only  excites  a  slight  and 
occasional  cough. 

Secondly. — I  have  said  the  patient  feels  no  pain,  and  the  sur- 
geon is  unconscious  of  danger,  when  an  abscess  thus  occupying 
the  neck  threatens  to  burst  into  the  throat :  the  danger  indeed 
is  of  a  nature,  which  practice  only,  and  not  theory,  could  enable 
you  to  predict.  While  the  disorder  has  not  reached  the  throat, 
its  effects  cannot  be  imagined,  so  entirely  is  the  simple  abscess 
free  from  harm,  or  the  appearance  of  harm,  the  displacement  of 
the  trachea,  the  uneasy  bulkiness  of  the  throat,  and  the  difficulty 
of  breathing  and  swallowing  excepted  :  nor  is  it  upon  its  first 
bursting  into  the  pharynx  that  the  ill  effects  of  it  are  perceived ; 
I  remember  one  coarse  country- fellow,  in  whom  two  large  scro- 
phulous  abscesses  of  this  complexion  had  burst  into  the  pharynx, 
but  except  a  hoarse  uncouth  voice,  and  difficulty  of  swallowing, 
he  had  as  yet  no  symptom  which  was  not  rather  ludicrous  than 
dangerous ;  for  you  distinguished  the  connexion  of  these  ab- 
scesses with  the  throat,  not  by  seeing  any  openings  internally, 
or  knowing  by  any  mark  that  matter  was  discharged  into  the 
throat ;  but  by  the  fellow  blowing  up  the  two  bags  at  will,  till 
they  resembled  the  alforges  of  a  baboon,  and  really  when  this 
resemblance  struck  you,  you  could  hardly,  on  looking  at  his 
ill  shaved,  grinning  muzzle,  think  them  at  all  misplaced.  By 
making  free  openings  on  each  side,  and  washing  and  cleaning 
the  sacs,  they  were  consolidated. 

But  when  such  abscess  lies  deep  behind  the  throat,  betwixt 
the  vertebrie  and  the  pharynx  ;  when  it  is  not  sensible,  nor  can 
be  opened  outwardly,  and  ulcerates  and  bursts  within,  a  sac  is 
formed,  accompanied  with  a  ruinous  disorder  of  the  structure 
and  function  of  the  part.  Even  before  the  abscess  bursts  into 
the  throat,  the  larynx,  or  cartilaginous  and  only  solid  part  of 
the  throat,  is  pressed  strongly  over  to  the  opposite  side  ;  the 
arches  of  the  palate  betwixt  which  (i.  e.  betwixt  the  anterior 


Of  Salivary  Tumours.  543 

and  posterior  arch)  the  tonsil  of  each  side  is  lodged,  are  so 
pressed  together  as  to  adhere  ;  the  secreting  surface  of  the  ton- 
sil is  thus  sealed  up,  and  covered  over  by  the  adhesion,  as  it  it 
had  never  been,  and  the  membrane  of  the  throat  becomes  flat 
and  shining,  its  natural  plies  are  obliterated,  and  th<  whole  is 
smoothed  into  one  level  surface,  till  new  constrictions  and  diseas- 
ed folds  and  ridges  are  formed. 

Thus,  by  the  very  first  adhesions,  the  throat  is  straitened  ; 
often  the  arches  of  the  palate  are  so  fixed  down  by  adhesions, 
that  the  whole  opening  from  the  throat  towards  the  nostrils  is 
closed  up,  or  is  almost  closed,  leaving  a  small  slit-like  opening, 
like  the  slit  in  a  poors'-box.  Now  there  is  a  perpetual  regurgi- 
tation of  the  food  and  drink,  suffocation,  so  that  the  eyes  stare 
in  the  head,  accompanying  every  attempt  to  swallow  :  the  air  is 
admitted  into  the  abscess,  and  the  matter  into  the  trachea  :  the 
tickling  cough  is  incessant,  the  expectoration  endless,  the  fits  of 
real  asthma  very  frequent.  The  admission  of  the  air  and  food 
into  the  abscess  mixing  with  the  pus,  gives  a  pestilent  foetor  to 
the  breath  ;  and  those  functions  of  speaking,  breathing,  swal- 
lowing, which  go  on  in  the  natural  state  of  the  parts  without 
consciousness,  or  any  sensible  efforts,  are  now  a  perpetual  strug- 
gle, and  if  the  patient  can  at  all  survive,  it  is  by  being  careful  to 
swallow  little  drops  of  fluid,  and  little  morsels  of  nourishment 
with  that  caution  which  is  absolutely  necessary  to  prevent  suffo- 
cation, which  yet  often  fails,  and  then  severe  struggles  and  suf- 
focation come  on. 

During  the  progress  of  the  disease,  the  thin  matter  of  the 
abscess  is  streaming  into  the  trachea,  while  the  coughing  and 
straining  supports  a  perpetual  state  of  ulceration  :  the  whole 
inside  membrane  of  the  throat  is  thickened  ;  that  glandular  sur- 
face surrounding  the  root  of  the  epiglottis,  and  named,  from  its 
natural  aspect,  caro  glandulosa,  is  thickened  and  exulcerated  ; 
the  mouth  of  the  glottis  has  its  lips  so  thickened,  that  it  is  no 
longer  flexible  nor  patent  ;  and  the  back  of  the  pharynx,  if  it 
be  not  hidden  by  the  adhesion  of  the  arches  of  the  palate,  is 
ulcerated,  grows  fibrous  and  stringy,  like  the  chordae  tendinea 
of  the  heart  ;  the  strings  which  cross  it  in  every  direction  are 
red,  and  ulcerated  ;  and  the  reticulated  interstices,  filled  with 
pus,  Which  you  see  sometimes  oozing  out  from  larger  ulcera- 
tions and  cavities.  These  are  changes  of  structure,  which  oc- 
casion a  very  protracted  scene  of  suffering  ;  the  patient  walks 
with  his  chin  resting  on  his  breast  to  relax  the  ulcerated  throat  ; 
his  usual  breathing  is  slow  and  difficult,  accompanied  with  a 
lifting  of  the  chest  and  shoulders,  a  raising  of  the  eye-lids, 
an  anxious  contraction  of  the  features,  and  a  hissing  and 
stridulous  noise  j  he  is  perpetually  clearing,  or  attempting  to 


544  Of  Salivary  Tumours. 

clear  the  thickened  and  encumbered  trachea  coated  with  mu- 
cus, and  this  action  is  so  incessant,  that  it  seems  necessary  to 
his  breathing  at  all.  The  voice  is  whispering,  and  when  forced 
degenerates  into  a  sort  of  screech  :  the  arches  of  the  palate, 
while  they  contract  and  close  over  the  tonsils,  adhere  also  to  the 
Eustachian  tubes,  so  that  the  hearing  is  almost  lost,  whence  the 
patient,  in  conversing  with  yon,  always  turns  his  head  and  lays 
his  ear  to  hear  you.  His  breathing  is  habitually  difficult,  so  that 
the  blood  is  driven  into  the  head,  and  he  passes  much  of  the  day 
and  all  the  night  in  a  lethargic  stupor,  each  fit  of  anxious 
breathing  being  followed  by  oppressive  head-ach,  and  increa- 
sing stupor.  He  rises  during  the  night  in  asthmatic  parox- 
ysms, and  exposing  himself  to  an  open  window,  finds  a  slight 
relief,  and,  returning  again  to  bed,  falls  into  an  apoplectic  stu- 
por, from  which,  even  at  mid-day,  he  is  roused  with  difficulty. 
At  last,  becoming  truly  apoplectic,  he,  in  some  unusual  parox- 
ysm of  asthma,  runs  to  the  window,  throws  open  his  neck  and 
breast,  grasps  at  something  for  support,  and,  no  longer  able  to 
sustain  the  struggle,  he  falls  into  a  fit  of  stupor,  his  head  drops 
forward,  his  limbs  relax,  and  he  falls  down  and  is  found  dead. 
This  is  the  dreadful  conclusion  of  the  scene  where  the  slow 
thickening  of  the  internal  membrane  of  the  throat,  and  espe- 
ciallv  the  induration  of  the  glottis,  is  the  cause  of  his  death. 

Thirdly. — I  know  not  whether  this  labouring  and  dreadful 
condition,  much  as  I  have  sympathized  with  those  who  have 
died  so,  is  the  worst,  for  often  the  disorder  is  more  complicated 
by  big  and  capacious  sacs  of  matter  bursting  into  the  throat ; 
and  the  death  of  the  patient,  though  less  lingering,  is  more  ter- 
rible. When  a  great  abscess  is  permitted  to  undermine  all  the 
cellular  substance  of  the  throat,  and  surround  the  oesophagus, 
there  are  no  limits  to  the  number  of  openings  :  it  bursts  at  va- 
rious points  into  both  oesophagus  and  larynx :  the  openings  into 
the  tube  are  as  various  and  perplexing  as  those  around  a  diseas- 
ed urethra,  and  it  is  as  difficult  to  find  the  true  passage,  so.as 
to  convey  nourishment  to  the  patient.  The  openings  are  large, 
oblique,  and  valve-like,  and  often  surrounded  with  strings  of  in- 
durated fibres,  resembling  the  openings  in  the  auricles  of  the 
heart:  these  mouths  of  the  abscess  are  as  large  and  open,  to 
receive  whatever  fluid  or  solid  the  patient  tries  to  swallow  ; 
the  food  and  drink  pass  sometimes  into  the  trachea,  sometimes 
into  the  sacs,  sometimes  they  regurgitate  with  great  violence  by 
the  nostrils,  going,  in  short,  in  every  direction  but  down  the 
natural  passage,  which  being  fleshy  collapses,  while  the  slits  in 
the  solid  larvnx,  or  cartilaginous  part  of  the  throat,  present 
themselves  to  receive  the  morsel,  or  a  part  of  it ;  and  the  bag, 
when  distended  bv  food,  or  drink,  or  air  thus  pressed  into  it  by 


Of  Salivary   Tumours.  545 

the  action  of  the  throat,  comprt  sses  the  oesophagus.  Where 
there  is  less  of  general  ulct- ration  and  thickening  of  the  mem- 
brane, and  the  sac  compressing  the  oesophagus  is  large,  the  pa- 
tient is  rather  starved  than  suffocated  ;  he  retains  all  his  facul- 
ties, makes  every  effort  to  receive  food,  he  falls  into  fits  of  suf- 
focation only  when  he  tries  to  drink,  and  actually  dies  of  fa- 
mine. His  condition  gives  a  greedy  eager  expression  to  his 
features,  and  a  wild  and  hurried  manner  to  all  his  actions  ;  he 
wishes  for  food,  yet  knows  he  cannot  swallow  ;  he  has  an  irre- 
sistible desire  for  drink,  but,  when  he  endeavours  to  pour  it 
down,  it  is  rejected  by  his  nostrils  :  the  struggle  for  breath  con- 
tinues long  after  each  attempt  to  swallow,  and  shrinks  up  his 
features  into  a  rigid  grinning  form  ;  his  shoulders  are  raised, 
his  lean  and  skinny  hands  sprawling  and  extended,  his  visage  is 
pale,  and  meagre,  his  nostrils  dilated,  his  forehead  wrinkled, 
high,  his  eye-balls  staring  from  their  hollow  sockets,  the  angles 
of  his  mouth  retracted,  and  the  viscid  saliva,  which  he  has  not 
power  to  swallow,  distils  in  strings  from  his  mouth.  Such  is 
the  dread  I  ul  condition  to  which  a  patient  is  reduced  by  that  ig- 
norance and  indiff  rence  to  slighter  signs  of  disorder,  which  are 
so  common  with  the  vulgar,  or  by  the  surgeon  allowing,  for  fear 
of  danger,  any  deep-stated  abscess  to  burst  thus  into  the  throat. 

Even  after  the  tumour  has  burst  into  the  throat;  it  is  not  too 
late  to  cure  the  abscess  ;  it  seems  to  me  that  a  dependent  opening 
will,  by  emptying  the  sac,  prevent  those  disorders  which  only 
long  continued  ulceration  and  complicated  openings  occasion.* 

"  James  Ogilvv,  a  man  of  middle  age,  has  a  deep  scrophulous 
abscess  occupving  the  right  side  of  the  neck,  displacing  the  tra- 
chea, and  pointing  in  the  throat :  how  long  it  may  have  existed 
he  does  not  know,  but  six  months  ago  it  became  very  promi- 
nent, especially  towards  the  lower  part  of  the  neck,  affecting  his 
breathing  and  swallowing,  yet  that  very  slightly,  and  accompa- 
nied with  no  sense  of  uneasiness  nor  pain  :  but  soon  after,  how- 
ever, the  tumour  appeared  in  the  lower  part  of  the  neck,  it  be- 
came painful,  and,  about  four  months  ago,  the  swelling  began 
to  be  felt  in  the  mouth ;  this  stage  of  the  distention  was  accom- 
panied with  violent  pain.  Since  then  the  swelling  has  increa- 
sed continually,  though  slowly  ;  the  swelling  in  the  lower  part 
of  the  neck  is  diffused,  soft,  and  colourless;  within  the  throat 
in  the  fauces,  it  appears  large,  soft,  fluctuating,  equably  convex, 
and  apparently  filling  the  whole  of  the  pharynx ;  the  pain  is 
gone,  but  the  respiration  is  affected,  deglutition  extremely  cliffi- 

*  Should  the  tumour  burft  into  the  trachea  by  a  large  opening,  fuffocatioi' 
would  probably  immediately  take  place.  Should  the  matter  make  its  way  into  the 
pharynx  the  patient  might  recover,  but  if  it  was  difcharged  jnro  the  larynv  h< 
would  moll  probably  die.     S. 

3   Z 


546  Of  Salivary  Tumours. 

cult,  and  the  abscess  is  so  tumid,  that  you  would  expect  it  to 
burst  immediately,  and  widclv,  into  the  pharynx  ;  indeed,  al- 
though the  abscess  thus  preserves  its  convexity,  I  cannot  but  be 
persuaded,  that  there  is  already  a  partial  opening  betwixt  the 
horns  of  the  os  hyoides,  and  those  of  the  thyroid  cartilage,  at  a 
point  where  we  cannot  see  the  ulcer.  I  am  persuaded  of  this 
from  the  incessant  cough  and  perpetual  discharge  of  matter:  he 
has  a  hectic  visage,  and  a  fretful  pulse,  and  the  circumstances 
of  the  abscess  admit  of  no  delay. 

"On  the  25th  of  July  this  great  abscess  was  opened  by  an 
incision  in  the  lower  part  of  the  neck,  and  nearly  three  pounds  of 
thick  yellow  pus  were  discharged.  The  neck  flattened,  the  re- 
spiration and  deglutition  became  easy,  and  the  internal  swelling, 
viz.  that  which  appeared  within  the  throat,  disappeared:  the 
abscess  was  carefully  washed  out  with  injections,  and  every  care 
taken  to  keep  the  cavity  of  this  enormous  sac  clean,  and  to  sup- 
port the  patient's  strength  and  prevent  fever. 

"  But  it  rarely  happens  that  so  great  an  abscess  is  opened 
without  hectic  :  the  discharge  was  very  profuse  and  thin,-  his 
pulse  rose  from  80  to  112,  he  complained  of  great  weakness, 
and  had  night-sweats,  while  his  skin  was  burning  hot,  and  his 
tongue  white  :  the  fever  continued  with  little  abatement  for  ten 
days,  for  eight  da\s  more  it  continued  increasing,  so  that  his 
life  seemed  endargered,  but  as  yet  we  were  not  conscious  of 
anv  other  cause  than  the  great  extent  of  this  abscess  and  the 
profuse  secretion  of  pus,  when  suddenly  the  abscess  within  the 
throat,  which  seemed  to  be  emptied  through  the  incision  below, 
but  had  only  subsided,  burst  into  the  pharvnx;  then  his  ano- 
dynes procured  him  rest,  the  bark  sat  pleasantly  on  his  stomach, 
his  food  nourished  him,  his  appetite  and  strength  increased 
every  day,  the  discharge  which  now  became  very  moderate, 
sometimes  almost  ceased  at  the  external  opening,  and  then  to- 
tally ceased  from  the  abscess  of  the  throat:  at  last,  at  the  end 
of  six  weeks,  he  was  permitted  to  retire  to  the  country  to  live 
on  milk  and  take  gentle  exercise,  with  every  prospect  of  a  per- 
fect cure." 

The  condition  of  the  poor  creature,  whose  case  I  am  now 
to  describe,  was  wretched  in  the  last  degree.  The  only  open- 
ing left  betwixt  the  nostrils  and  the  mouth,  or  top  of  the  pha- 
rynx, is  slit-like,  and  no  bigger  than  to  permit  a  farthing  to 
pass  into  it  edge-ways;  the  arches  of  the  palate,  and  the  velum 
palati,  or  soft  and  moveable  palate,  have  both  adhered-  so  to 
the  back  of  the  pharynx  as  to  seal  down  the  tonsils,  and  the 
face  of  both  tonsils  is  so  covered  by  this  adhesion,  that  even 
the  place  where  the  tonsils  should  be  ,  is  not  to  be  perceived  ; 
and  the  adhesion  of  the  arches  of  the  palate  is  so  complete,  as 


Of  Salivary  Tumours.  54?7 

to  leave  only  this  slit-like  opening.     This  slit-like  opening  only 
was  visible  during  life  ;  for  the   ulcerated  openings  from   the 
abscess  into  the  pharynx,  lay  opposite  to  the  glottis,  and  so  far 
below  the  root  of  the   tongue,  as  not  to  be  seen,  or  even  sus- 
pected in  any  other  way,  than  by  the  catheter  (when  we  at- 
tempted to  pass  it  into  the  oesophagus)  slipping  into  them  :  the 
mechanism  of  the  throat  was  entirely  ruined,  and  the  larynx, 
irritable  even  in  its   healthy  state,  was  kept  in  a  perpetual  irri- 
tation and  struggle,  in  a  state  of  asthmatic  constriction  at  all 
times,  and  in  a  state  of  absolute  strangulation  upon  the  slightest 
attempt  to  swallow.      The  effects  of  every  attempt  10  take  down 
food  or  drink  may  be  easily  imagined,  from  the  relation  oi  the 
parts  ;  for,  first,  the  glottis  and  epiglottis,  the  parts  which  should 
be  in  perpetual  motion  to  prevent  accidents  in  swallowing,  were 
stiffened  by  ulceration  and    thickening  :   secondly,   the  opening 
of  the  pharynx  into  the  oesophagus  by  which   the  food  should 
descend  into  the  stomach,  was  distorted  and  obstructed,  both 
by  the  pressure  of  the  abscess  behind,  and  by  the  cartilaginous 
part  of  the  trachea,  the   larynx  being  drawn   continually  back- 
wards by  the  stvlo-hvoidei   muscles,  in  the  incessant  spasms  of 
the  whole  throat :  thirdly,  the  valve-like  openings  of  the  abscess 
or  abscesses,  (for  abscesses  appeared  during  life  to  occupy  both 
sides  of  the  jaws  and   throat)  presented  themselves   more   di- 
rectly than  the  openings  ol  the  oesophagus,  receiving  everv  mor- 
sel of  food  or  drop  of  fluid.     The  mechanism   of  the  throat 
was  so  changed,  that  the  more  violently  the  efforts  to  swallow 
food  or  nourishment   were  excited,  the  more  effectually  was 
the  purpose  defeated,  for,  when  the  whole  force  of  the  throat, 
tongue,  and  muscles  of  deglutition  was  exerted  to  force  down 
the  morsel,  the  oesophagus  received  not  a  particle  of  what  was 
destined  for  the  stomach,  the  whole  force  therefore  of  the  mus- 
cles of  deglutition  was  spent  in  injecting  the  sac  of  the  abscess 
with  the    food  or  drink.     The  sac,  large   and   capacious  as  it 
was,  soon  filled  ;  and  no  sooner  filled,  than  it  effectually  com- 
pressed the  oesophagus  ;  the  food  or  drink    ran  over  into  the 
trachea,  and,  by  the  effort  which  this  instantly  excited,  the  con- 
tents of  the  bag,  along  with  the  last  mouthful  of  the  fluid,  were 
rejected  through  the  nose.     It  was  in  this  condition,  in  this  last 
stage  of  his   malady,  that  I  saw  this  wretched  man  :  he  was 
meagre  and  staring  with  famine,  his  belly  clung  to  his  back,  his 
skin  to  his  bones,  his  face  was  squalid,  lean,  and  yellow,  bis 
voice  hollow  and  rattling,  his  gray  eyes  sunk  in  their  sockets, 
the  eye-lids  and  skin  of  the   forehead  raised  and   wrinkled  in 
deep  furrows  :  whenever  he  moved  he  was  in  danger  of  suffo- 
cation :  the  slightest  attempt  to  swallow  was  accompanied  with 
a  struggle,  which  he  seemed  hardly  capable  of  surviving  :  his 


548  Of  Salivary  Tumours. 

skinny  hands  and  sprawling  lean  fingers,  were  perpetually  ex- 
tended before  him,  as  if  ready  to  catch  at  something  for  sup- 
port, when  the  strangulation  came  upon  him  :  he  had  neither 
strength  nor  voice,  to  tell  me  the  date  nor  the  cause  of  his  suf- 
ferings, and,  though  the  abscesses  on  each  side  of  his  jaws, 
extending  along  the  neck,  varying  in  their  state  of  fulness,  and 
bulging  upon  every  attempt  to  swallow,  explained  his  condi- 
tion in  part,  yet  in  honest  truth  I  mistook,  at  first,  the  slit-like 
opening  above  mentioned  for  the  way  into  the  oesophagus,  till 
I  found  that,  in  place  of  admitting  the  lithotomy  staff  which  I 
used  as  a  probe,  to  pass  downwards  into  the  pharynx,  it  only 
entered  when  turned  with  the  point  upwards  towards  the  nos- 
tril. Satisfied  and  instructed  in  this  point,  and  knowing  part 
of  the  disorder,  viz.  that  the  arches  of  the  palate  had  closed 
and  adhered,  I  sought  the  passage  downwards,  and  having 
passed  the  flexible  catheter  into  the  oesophagus,  I  poured  down 
by  the  syringe  a  basin  of  warm  beef-tea,  the  first  meal  he  had 
enjoyed  for  a  long  while,  and  which  he  acknowledged  to  be 
very  grateful.  But  neither  this  first  operation,  nor  any  subse- 
quent one,  was  easy  ;  I  knew  nothing  precisely  concerning  the 
ulcerated  openings  leading  into  the  sac  ;  often  when  the  cathe- 
ter seemed  to  pass  into  the  oesophagus,  it  plumped  into  the  sac, 
its  point  was  resisted,  and  it  was  only  by  its  stopping  short 
thus,  that  I  was  aware  of  the  tube  having  missed  the  pharynx  ; 
upon  such  occasions  I  withdrew  it  to  try  again  for  the  true 
passage  :  the  catheter  was  always  passed  two  or  three  times, 
before  it  actually  entered  the  oesophagus  ;  it  was  only  when  it 
passed  easily  and  quite  down  into  the  throat,  that  I  durst  ven- 
ture to  pour  in  the  soup  ;  sometimes  it  went  into  the  opening 
of  the  larynx,  and,  though  instantly  withdrawn,  excited  such  a 
suffocation  as  was  very  alarming.  I  fear  that  the  pupil  to  whom 
I  entrusted  the  passing  of  the  catheter,  and  the  nourishment  of 
the  patient,  had  actually  failed,  and  concealed  his  own  awk- 
wardness from  me  :  I  cannot  but  reflect  with  self-reproach  on 
my  own  remissness  in  not  passing  the  catheter  regularly  my- 
self :  but,  I  believe,  this  complicated  disorder  was  quite  incu- 
rable ;  the  poor  man  grew  more  ghastly  in  the  visage,  and 
weaker  every  hour,  and,  while  we  were  engaged  in  contriving 
how  the  sac  might  be  opened,  or  what  should  be  done,  he  ex- 
pired on  the  fourth  day."* 

I  have  now  narrated  much  of  what  1  have  seen  or  done,  in 
tumours  of  the  head  and  throat,  diseases  always  dangerous  in 


•  Where  the  catheter  is  to  be  paffed  into  the  oefophagus  for  the  purpofe  of 
conveying  food  into  the  ftomach,  it  had  better  be  introduced  through  one  of  the 
noftril*,  as  pradtiled  by  Default.     S. 


Of  Salavary  Tumours.  549 

their  tendency,  by  affecting  respiration  and  deglutition,  and  in 
which  we  must  often  decline  operating,  from  their  roots  being 
entangled  with  the  great  arteries  and  nerves.  Often  when  I 
have  seen  a  patient  dying  in  a  miserable  and  lingering  manner 
I  have  wondered  that  no  other  means  of  extirpation  has  ever 
been  proposed,  than  that  which  the  knife  affords,  nor  any  de- 
sign invented,  by  which  tumours  might  be  forced  to  suppurate. 
To  express  such  a  thought  implies  that  a  scheme  of  this  nature 
has  presented  itself  to  my  imagination,  such  as,  I  think,  may 
be  successful  :  it  is  so,but  being  yet  untried  I  am  bound  to  sub- 
mit the  following  suggestion  to  you  with  diffidence,  and  to  men- 
tion it  without  much  detail,  and  with  becoming  modesty  and 
reserve. 

Tumours  refuse  to  suppurate  when  their  substance  is  pecu- 
liarly solid,  disease  having  obliterated  the  cellular  substance  ol 
the  part :  tumours  also  are  difficult  to  extirpate  ;  and  often,  in 
consequence  of  a  hurried,  bloody,  and  imperfect  dissection,  much 
of  the  disease  is  left  behind,  because  successive  inflammations 
have  hardened  or  filled  up  the  cellular  substance  which  sur- 
rounds the  gland,  and  consolidated  it  as  it  were  into  one  mass 
with  the  surrounding  skin  and  flesh  :  but  could  we  venture,  to 
inject  the  more  solid  tumours,  so  as  to  restore  by  moderate  vio- 
lence the  cellular  interstices,  among  its  integral  parts  ;  or  could 
we  surround  and  insulate  an  apparantly  immovable  tumour 
from  its  manifold  adhesions,  by  an  injection  which  would  pur- 
sue whatever  remained  of  the  tela  cellulosa  from  cell  to  cell,  we 
should  perhaps  attain  this  desirable  end,  of  forcing  the  one  spe- 
cies of  tumour  into  a  state  of  suppuration,  and  disengaging  the 
other  from  the   surrounding  parts. 

What  is  it  peculiar  in  the  texture  of  a  tumour  that  prevents 
suppuration  ?  what  is  the  character  which  implies  that  it  is  ca- 
pable of  being  resolved  ?  a  stony  hardness  ,  and  extreme  specific 
gravity,  indicating  that  the  cellular  substance  is  quite  oblitera- 
ted, that  there  is  no  interstitial  substance  to  receive  those  secre- 
tions, which  are  by  time  matured  into  pus  :  thence  it  is  that  in 
glands  indurated  to  this  degree,  schirrous  as  they  are  named, 
vascular  action  being  excited  by  a  blow  or  fall,  and  accompa- 
nied or  relieved  by  no  secretion  ,  occasions  only  pain,  ulceration, 
partial  gangrene  in  each  bursting  part,  and  a  thin  and  watery 
ichor,  which  is  itself  an  animal  poison.  The  blow-pipe  forced 
into  any  tumour  wrould,  by  successive  attemps,  form  those  in- 
terstices, and  injecting  the  part  with  oily  and  camphorated  so- 
lutions, would  force  suppuration  in  the  diseases  of  the  salivary, 
or  thyroid,  or  lymphatic  glands,  where  no  opperation  could  be 
attempted  ;  and,  in  tumours  even  of  the  mamma,  it  might  be 
advantageous  to  disengage  the  part  by  such  injections,  as  would 


550  Of  Salivary    Tumours. 

throw  all  the  surrounding  cellular  substance  into  suppuration, 
the  part  itself,  incapable  of  suppuration,  would  thus  be  insu- 
lated and  might  be  turned  out  like  a  kernel  from  its  husk. 
Su^h  spontaneous  suppurations  of  the  surrounding  cellular 
substance-,  and  such  happy  deliveries  from  a  desperate  dis- 
ease, we  have  witnessed  manv  times ;  and  what  I  have  now 
proposed,  though  not  without  many  difficulties  and  objec- 
tions, is  too  strong  in  analogies  not  to  be  worthy  of  some  de- 
gree of  notice.  i  know  not  how  any  tumour  could  resist  this 
practice :  what  dangerous  consequences  could  ensue  ?  none 
worse  than  such  suppuration.  Gangrene,  or  sloughing,  as  it  is 
called,  when  thus  local,  would  be  limited  to  the  cellular  sub- 
stance and  skin,  and  the  operations  ol  inflating  or  injecting  a 
tumour  for  the  purpose  of  suppurating  or  of  unrooting  it,  could 
be  conducted  with  such  prudence,  and,  being  of  the  nature  of  an 
experiment,  would  be  attempted  by  such  gentle  degrees,  as 
would  save  us  from  self-reproach,  or  the  misery  of  doing  harm 
where  we  intended  good. 

I  have  read  somewhere  of  an  expression,  which  often  re- 
turns upon  my  ear,  "Examples  are  eloquent;"  I  have  ever 
found  them  the  most  precious  lessons,  and  been  at  pains  through 
all  my  life  to  record  them  with  care  and  precision  :  our  reason- 
ing on  every  professional  question,  and  our  proceedings  in  every 
new  case,  must  be  regulated  by  precedents,  and  I  have  laid  be- 
fore you  such  examples,  and  deduced  from  them  such  lessons, 
as  you  will  not  despise,  for  they  are  the  fruits  of  experience. 
Of  all  professional  questions,  that  concerning  the  nature,  ten- 
dency, and  future  consequences  of  a  tumour,  seems  to  me  the 
most  solemn :  the  physician  or  surgeon  may  but  too  easily  rid 
themselves  of  the  importunity  of  a  patient  afflicted  with  a  dan- 
gerous tumour,  for  if  they  will  but  pronounce  any  projected  ope- 
ration fatal,  the  patient  will  retire  from  public  view,  mourn  over 
his  helpless  and  miserable  state  in  solitude,  and  die  a  willing 
martyr  to  their  opinion,  and  to  the  too  natural  abhorrence  of 
pain,  and  the  fear  of  expiring  at  once  from  loss  of  blood. 


APPENDIX. 


A 


JL  HE  following  explanation  of  the  process  employed  by  nature  in 
arresting  the  hemorrhage  from  divided  arteries,  appears  to  me  tp  be 
much  more  satisfactory  than  Mr.  Bell's.  For  the  experiments  and 
facts,  which  prove  it,  the  reader  is  referred  to  the  work  from  which 
it  is  extracted,  "  Jones  on  Hemorrhage." 

"  The  results  of  the  experiments  related  in  the  last  section  will  not 
allow  us  to  give  so  concise  and  simple  an  account  of  the  process,  as 
has  hitherto  been  done  ;  but  they  afford  us  one  more  satisfactory, 
because  it  accords  belter  with  the  operations  of  theanimal  oeconomy, 
in  which  we  are  accustomed  to  observe  the  most  important  changes 
gradually  produced  by  the  co  operation  of  several  means,  rather 
than  by  the  sole  influence  of  any  one  in  particular. 

"  They  accordingly  shew,  that  the  blood,  the  action  and  even  the 
structure  of  arteries,  their  sheath,  and  the  cellular  substance  connec- 
ting them  with  it — in  short,  that  all  the  parts  concerned  in  or  affect- 
ed by  hemorrhage,  contribute  to  an  est  its  fatal  progress,  by  operating, 
in  the  case  of  a  divided  artery  of  moderate  size,  in  the  following 
manner. 

"  An  impetuous  flow  of  blood,  a  sudden  and  forcible  retraction  of 
the  artery  within  its  sheath,  and  a  slight  contraction  of  its  extremity, 
are  the  immediate  and  almost  simultaneous  effects  of  its  division. 
The  natural  impulse,  however,  with  which  the  blood  is  driven  on, 
in  some  measure  counteracts  the  retraction,  and  resists  the  contrac- 
tion of  the  artery.  The  blood  is  effused  into  the  cellular  substance 
between  the  artery  and  its  sheath,  and  passing  through  thatc«nal  of 
the  sheath  which  had  been  formed  by  the  retraction  of  the  artery, 
Hows  freely  externally,  or  is  extravasated  into  the  surrounding  cellu- 
lar membrane,  in  proportion  to  the  open  or  confined  state  of  the  ex- 
ternal wound.  The  retracting  artery  leaves  the  internal  surface  of 
the  sheath  uneven  by  lacerating  or  stretching  the  cellular  fibres  that 
connected  them.     These  fibres  entangle  the  blood  as  it  flows,  and 


552  Appendix. 

thus  the  foundation  is  laid  for  the  formation  of  a  coagulum  at  the 
mouth  of  the  artery,  and  which  appears  to  be  completed  by  the  blood, 
as  it  passes  through  this  canal  of  the  sheath,  gradually  adhering  and 
coagulating  around  its  internal  surface,  till  it  completely  fills  it  up 
from  the  circumference  to  the  centre. 

"  A  certain  degree  of  obstruction  to  the  hemorrhage,  which  re- 
sults from  the  effusion  of  blood  into  the  surrounding  cellular  mem- 
brane, and  between  the  artery  and  its  sheath,  but  particularly  the 
diminished  force  and  velocity  of  the  circulation,  occasioned  by  the 
haemorrhage,  and  the  speedy  coagulation  of  the  blood,  which  is  a 
well  known  consequence  of  such  diminished  action  of  the  vascular 
system,  most  essentially  contribute  to  the  accomplishment  of  this 
important  and  desirable  effect. 

"  A  coagulum  then,  formed  at  the  mouth  of  the  artery,  and  with- 
in its  sheath,  and  which  I  have  distinguished  in  the  experiments  by 
the  name  of  the  external  coagulum,  presents  the  first  complete  bar- 
rier to  the  effusion  of  blood.  This  coagulum,  viewed  externally, 
appears  like  a  continuation  of  the  artery,  but  on  cutting  open  the 
artery,  its  termination  can  be  distinctly  seen  with  the  coagulum  com- 
pletely shutting  up  its  mouth,  and  inclosed  in  its  sheath. 

"  The  mouth  of  the  artery  being  no  longer  pervious,  nor  a  colla- 
teral branch  very  near  it,  the  blood  just  within  it  is  at  rest,  coagu- 
lates, and  forms,  in  general,  a  slender  conical  coagulum,  which 
neither  fills  up  tue  canal  of  the  artery,  nor  adheres  to  its  sides,  ex- 
cept by  a  small  portion  of  the  circumference  of  its  base,  which  lies 
near  the  extremity  of  the  vessel.  This  coagulum  is  distinct  from 
the  former,  and  I  have  called  it  the  internal  coagulum. 

"  In  the  mean  time  the  cut  extremity  of  the  artery  inflames,  and 
the  vasa  vasorum  pour  out  lymph,  which  is  prevented  from  escaping 
by  the  external  coagulum.  This  lymph  fills  up  the  extremity  of  the 
artery,  is  situated  between  the  internal  and  external  coagula  of 
blood,  is  somewhat  intermingled  with  them,  or  adheres  to  them, 
and  is  firmly  united  all  round  to  the  internal  coat  of  the  artery. 

"  The  permanent  suppression  of  the  hemorrhage  chiefly  depends 
on  this  coagulum  of  lymph  ;  but  while  it  is  forming  within,  the  ex- 
tremity of  the  artery  is  farther  secured  by  a  gradual  contraction 
which  it  undergoes,  and  by  an  effusion  of  lymph  between  its  tunics, 
and  into  the  cellular  membrane  surrounding  it ;  in  consequence  of 
which  these  parts  become  thickened,  and  so  completely  incorporated 
with  each  other,  that  it  is  impossible  to  distinguish  one  from  the 
other  :  thus,  not  only  is  the  canal  of  the  artery  obliterated,  but  its 
extremity  also  is  completely  effaced,  and  blended  with  the  surround- 
ing parts. 

"  From  this  view  of  the  subject  we  can  no  longer  consider  the  sup- 
pression of  hemorrhage  as  a  simple  or  mere  mechanical  effect,  but 
as  a  process  performed  by  the  concurrent  and  successive  operation 
of  many  causes :  these  may  briefly  be  stated  to  consist  in  the  re- 
traction and  contraction  of  the  artery ;  the  formation  of  a  coagulum 


jf/ifiendix.  553 

at  its  mouth  ;  the  inflammation  and  consolidation  of  its  extremity  by 
an  effusion  of  coagulating  lymph  within  its  canal,  between  its  tunics 
and  in  the  cellular  substance  surounding  it." 


To  Dr.  Jones,  likewise,  we  are  indebted  for  a  more  complete  ex- 
planation of  the  effect  of  liga  ures  upon  arteries,  than  that  given  by 
Mr.  bell.  The  following  account  i9  extracted  from  p.  153 — 4-  of  his 
work. 

"  1.  To  cut  through  the  internal  and  middle  coats  of  the  artery  : 
and  to  bring  the  wounded  surfaces  into  perfect  opposition. 

"  2.  To  occasion  a  determination  of  blood  on  the  collateral 
brandies. 

'*  3.  To  allow  of  the  formation  of  a  coagulum  of  blood  just  with- 
in the  artery,  provided  a  collateral  branch  is  not  very  near  the  liga- 
ture. 

w  4.  To  excite  inflammation  on  the  internal  and  middle  coats  of 
the  artery  by  having  cut  them  through,  and  consequently,  to  giv« 
rise  to  an  effusion  of  lymph,  by  which  the  wounded  surfaces  are 
united,  and  the  canal  is  rendered  impervious  :  to  produce  a  simulta- 
neous inflammation  on  the  corresponding  external  surface  of  the  ar- 
tery, by  which  it  becomes  very  much  thickened  with  effused  lymph  ; 
and  at  the  same  time  from  the  exposure  and  inevitable  wounding  of 
the  surrounding  parts,  to  occasion  inflammation  in  them,  and  an 
effusion  of  lymph,  which  covers  the  artery,  and  forms  the  surface 
of  the  wound. 

"  5.  To  produce  ulceration  in  the  part  of  the  artery  round  which 
the  ligature  is  immediately  applied,  viz.  its  external  coat. 

a  6.  To  produce  indirectly  a  complete  obliteration,  not  only  of  the 
canal  of  the  artery,  but  even  of  the  artery  itself  to  the  collateral 
brandies  on  both  sides  of  the  part  which  has  been  tied. 

"  7.   To  give  rise  to  an  enlargement  of  the  collateral  branches. 

"  In  the  account  which  I  have  no>v  given  of  the  effects  of  the  liga- 
ture on  the  artery,  I  have  had  in  view  only  those  instances,  in  which 
the  ligature  has  been  applied  on  the  extremity  of  a  divided  artery,  or 
those  in  which  two  ligatures  have  been  applied  on  an  artery,  at  a 
small  distance  from  each  other,  and. the  intermediate  portion  divid- 
ed. But,  from  observation  on  the  human  subject,  it  appears,  that  the 
effects  are  different,  or  at  least  their  accomplishment  is  much  more 
likely  to  be  interrupted,  when  one  or  two  ligatures  are  applied  on  an 
artery  without  any  subsequent  division  of  it." 


Dr.  Jones  has  fully  proved  that  there  is  not  so  much  danger  to 
be  apprehended  from  drawing  the  ligature  upon  the  artery  with  con- 
siderable firmness  ;  if,  however,  the  surgeon  should  be  afraid  of  the 

4  A 


jijijicndix. 

ligature's  being  thrown  off  by  the  force  of  the  circulation,  he  may 
absolute'y  prevent  it  by  passing  the  needle  through  the  coats  of  the 
artery,  between  its  mouth  and  the  forme  i  ligature  and  lying  another 
knot.  After  doing  this,  the  ligature  cannot  be  pulled  away  without 
great  force  is  used. 

In  addition  to  what  Mr.  Bell  has  said  upon  the  subject  of  seconda- 
ry hemorrhage,  the  following  observations  are  extracted  Irom  Dr. 
Jones's  work  p,  l  a  l,  and  seq. 

"  There  is  yet  another  cause  of  secondary  hemorrhage,  which, 
although  I  have  hinted  at  it  once  or  twice  in  the  preceding  partsoof 
this  treatise,  I  have  not  yet  represented  it  in  the  important  point  of 
view  which  it  ought  to  be.  1  allude  to  the  sudden  separation  or  la- 
ceration of  the  recently  united  pails  of  an  artery  by  premature  and 
extraordinary  exertions  of  the  patient. 

''That  newly  cicatrized  wounds  may  easily  be  lorn  asune'er,  for  a 
certain  time  after  their  union,  a  sufficient  number  of  proofs  might  be 
adduced,  if  any  were  required,  from  the  operation  for  the  hare  lip  ; 
bui  in  these,  and  other  instances  of  disunited  wounds  in  Meshy  parts, 
the  united  surfaces  had  been  more  or  less  broad,  and-  of  course, 
their  adhesion  proportionably  strong  ;  whereas  in  the  case  of  a  re- 
cently united  artery,  the  cicatrized  part  is  a  mere  line,  and,  conse- 
quently, weak,  and  easily  torn  through:  it  is,  therefore,  of  the  ut- 
most impoitance  to  keep  the  limb,  a  large  artery  ol  which  has  been 
tied,  in  a  state  of  the  most  perfect  rest,  and  to  prohibit  and  guard, 
as  much  as  possible,  against  the  patient's  making  any  sudden  or 
great  exertion.  In  the  case  of  amputation  which  gave  rise  to  Petit's 
invention  for  compressing  divided  arteries,  secondary  hemorrhage 
was  brought  on,  on  the  twenty -first  day  after  the  operation,  by  the 
patient's  raising  himself  suddenly  and  silting  up  in  bed.  On  this 
subject  Petit  makes  the  following  observation  :  "  But  in  every  case 
it  is  absolutely  necessary  that  the  patient  and  the  wounded  part 
should  remain  in  a  complete  slate  of  rest  :"*  in  which,  however,  he 
seems  rattier  to  have  had  in  view  the  perfect  formation  of  the  clot, 
for  he  afterwards  adds  :  "  because  the  formation  of  the  clot  is  dis- 
turbed by  a  change  of  position. "f  But  the  remark  is  not  the  less 
valuable  and  worthy  of  attention  :  nor  does  this  allusion  to  the  ciot 
prove  toai  he  was  ignorant  of  the  staeot  the  extremity  of  the  artery  ; 
for  in  a  former  memoir,  after  describing  how  he  conceived  the  par- 
ticular figure  of  the  clot,  formed  in  an  artery  that  had  heen  tied, 
would  prevent  haemorrhage,  even  though  the  extremity  of  the  artery 
should  ulcerate;  he  adds:  u  It  is  not  the  same  thing  when  some 
convulsion  or  some  other  violent  motion  on  the  part  of  the  patient 
causes  a  separation  of  the  ligature;  because  this  separation  happens 
before  the  vessel  is  perfectly  closed,  and  moreover,  the  coagulum, 
notwithstanding  its  figure,  is  pushed  with  such  violence  that  it  not 
only  escapes,  but  in  lis  passage  destroys  whatever  re- union  may  have 

•  Petit,  Memoires  dc  i'  Acad.  &c.  de  I'annce  1732. 
f  Ibid.  ibid. 


ji/i/ietidix.  5  55 

taken  place,  and  the  mouth  of  the  vessel  as  large  as  ever,  discharges 
the  blood  as  in  the  nrst  day  of  its  division. "J 

Scarpa,  in  his  (.realise  on  aneurism,  lays  great  stress  on  keeping 
the  patient  in  a  state  of  rest,  and  recommends  moderating  the  torce 
of  the  circulation,  by  bleeding  in  tne  first  instance,  if  it  should  be  ne- 
cessary, and  afterwards  keeping  the  patient  on  very  low  diet  for  some 
time,  tie  mentions  several  cases  in  which  secondary  hemorrhage 
took  place  several  weeks  after  tying  a  large  artery,  apparently  and 
in  all  probability,  troin  some  exertion  on  the  part  of  the  patient. 

D 

In  describing  the  manner  in  which  aneurisms  are  found,  Mr.  Bell 
states  what  was  universally  admitted  to  be  correct  at  the  lime  he 
wrote.  Since  that  tne  celeorated  Scarpa  has  published  a  work  upon 
aneurisms,  in  wbicn  he  has  proved,  that,  in  a  vast  majority  of  instan- 
ces at  least,  aneurism  is  the  effect  of  a  rupture  in  the  coats  of  the  ar- 
tery, the  consequence  of  violence  or  disease.  Scarpa,  uiueeu,  con- 
tends for  the  universality  of  this  breach  in  the  coals  ol  the  vessel,  but 
in  mis  he  is  perhaps  not  altogether  correct.  I  have  certainly  seen 
an  incipient  aneurism  which  appeared  to  be  the  eflect  of  dilatation, 
though  i  confess  1  did  not  examine  it  so  minutely  as  1  might  nave 
done,  as  ai  that  lime  no  doubts  were  entertained  on  this  subject.  The 
truth  now  appears  to  me  lo  be  this,  that  sometimes  in  the  incipient 
stage  of  aneurism,  the  internal  coat  of  the  artery,  at  least,  is  dilated, 
but  when  the  tumour  becomes  increased  in  size,  this  too  gives 
way. 

The  following  extract  from  Scarpa,!  contains  his  opinions  upon 
this  subject,  from  which  u  correct  idea  of  the  truth  or  fallacy  of  his 
doctrine  may  be  formed. 

k*  The  internal  coat  of  an  artery  being  ulcerated  or  lacerated  from 
a  slow  internal  cause  in  some  point  of  its  circumference,  (which  he 
supposed  always  happens  in  spontaneous  aneurism,)  tne  blood  im- 
pelled by  the  heart  begins  immediately  to  ooze  through  the  connec- 
tions of  the  fibres  of  the  muscular  coat,  and  gradually  lo  be  effused 
into  the  interstices  of  ihe  cellular  covering,  winch  supplies  tne  place 
of  a  sheath  to  the  injured  artery,  and  forms  for  a  certain  space,  a  kind 
o£ecc/uj?iwsis,ov  extravasation  of  bluod,  slightly  elevated  upon  the  arte- 
ry. Afterwards,  the  points  of  contact  between  ihe  fibres  of  the  muscu- 
lar coal  being  insensibly  separated,  the  arterial  blood  penetrating  be- 
tween them,  tills  and  elevates,  in  a  remarkable  manner,  the  cehuiar 
covering  of  ihe  artery,  and  raises  it  after  ihe  manner  of  an  incipient 
tumour.  Thus,  the  fibres  and  layers  of  the  muscular  coat  being 
wasted  or  lacerated,  or  simply  separated  from  each  ether,  the  arterial 
blood  is  carried  with  greater  force,  and  in  greater  quantity  than  be- 
fore, into  the  cellular  sheath  of  the  artery,  which  it  forces  more  out- 


;  Petit,  Mem.  de  l'Acad.  &c.  dc  funnee  1781. 
1-   See  YVifharf,  p.  73  &  feq. 


6  56  .1/ifiendir. 

wards  :  and,  finally,  the  divisions  between  the  interstices  of  the  cel- 
lular coal  being  ruptured,  converts  it  into  a  sac,  which  is  filled  With 
polypous  concretions,  and  with  fluid  blood,  and  at  last  forms,  properly 
speaking,  the  aneurismal  sac;  the  internal  texture  ol  which,  al- 
though apparently  composed  of  membranes  placed  one  o\er  the 
other,  is,  in  fact,  very  different  from  that  of  the  proper  coals  of  the 
artery,  notwithstanding  the  injured  artery,  both  in  the  thorax  and  in 
the  abdomen,  as  well  as  the  aneurismal  sac,  is  covered  externally, 
and  enclosed  within  a  commou  smooth  membrane. 

u  In  the  very  considerable  number  of  aneurisms  of  the  arch,  and 
of  the  thoracic  and  ventral  trunk  of  the  aorta,  commonly  regarded  by 
medical  men  as  true  or  encysted^  or  as  formed  by  a  dilatation  of  the 
proper  couts  of  the  great  artery,  which  1  have  had  an  opportunity  of 
examining,  I  have  not  found  a  single  one,  in  which  the  rupture  of 
the  proper  coats  of  the  artery  was  not  evident,  and  in  which,  conse- 
quently, the  aneurismal  sac  was  produced  by  a  substance  completely 
different  from  the  internal  or  muscular  coat  pf  the  injured  artery. 
To  ascertain  the  truth,  and  confirm  the  constancy  of  this  fact,  it  is 
not  necessary  that  one  should  bt  possessed  of  uncommon  knowledge 
in  the  art  of  dissection,  but  only  thai  he  be  disposed  to  see  things  as 
they  really  exist,  and  that  he  undertake  to  examine  the  aneurism  in 
the  situation  in  which  it  is  found,  and  without  removing  the  parts 
which  surround  it,  or  at  least  that  he  do  this  with  due  circumspec- 
tion. For,  as  I  have  asserted  above,  very  often  the  examination 
which  is  made  by  medical  men,  of  internal  aneurisms  in  the  dead 
subject,  consists  of  little  more  than  a  simple  division  of  the  fundus 
of  the  tumour,  without  paying  attention  to  the  cellular  sheath  which 
surrounds  the  artery,  above  and  below  the  place  of  the  aneurism, 
and  without  examining  the  disposition  and  particular  characters  of 
the  proper  coats  of  the  aneurismatic  artery,  and  comparing  it  with 
the  substance  which  forms  the  parietes  of  the  aneurismal  sac  ;  and 
what  is  still  worse,  the  aneurism  is  examined  by  some,  after  being 
removed  from  the  body,  and  filled  with  some  substance,  or  dried;  in 
which  preparations,  there  is  nothing  to  be  seen  but  confusion  and 
obscurity,  in  every  thing  which  relates  to  the  true  nature  and  struc- 
ture of  the  parts  by  which  the  tumour  is  formed. 

"  A  circumstance  very  important  to  be  known  relative  to  this 
subject,  has  been  hinted  at  above  ;  viz.  that  the  aneurismal  sac 
never  comprehends  the  whole  circumference  of  the  injured  artery, 
but  only  a  portion  of  the  arterial  tube,  to  which  the  tumour  is  united 
on  the  one  or  the  other  side.  At  this  place,"  the  aneui  ismal  sac  pre- 
sents, as  it  were,  a  species  of  constriction,  or  neck,  beyond  which 
the  sac  of  the  aneurism  is  more  or  less  enlarged,  or  expanded,  and 
sometimes  to  an  enormous  degree.  This  circumstance  would  never 
accompany  aneurism,  or  rather  quite  the  contrary  would  be  found, 
if  the  aneurismal  sac  were  produced  by  an  equable  distention  of  the 
tube  and  of  the  proper  membranes  of  the  aneurismatic  artery.  For, 
in  incipient  aneurisms,  at  least,  the  greatest  effect  of  the  distention 
acting  upon  the  tube  of  the  artery,  the  greatest  size  of  the  tumour 
Might  to  be  in  the  artery  itself,  or  in  the  beginning  or  root  of  the  ttt- 


A[ifiendix.  557 

mour,  and  the  least  at  its  fundus.  But  observation  demonstrates, 
that,  whether  the  aneurism  be  recent  and  small,  or  of  long  standing 
and  large,  the  passage  from  the  artery  is  always  narrow,  and  the 
fundus  of  the  aneurism,  the  farther  it  is  removed  from  the  artery, 
the  more  it  is  enlarged.  Another  circumstance  worthy  of  attention 
on  this  head,  which  I  have  likewise  pointed  out  above,  is,  (hat  the 
aneurismal  sac  is  always  covered  by  the  same  sofi  distendible  cellu- 
lar substance,  which  in  the  sound  state  surrounded  the  artery,  and 
united  it  to  the  adjacent  parts  ;  which  soli  cellular  substance,  sup- 
posing it  to  be  an  aneurism  of  the  arch,  or  of  the  thoracic  trunk  of 
the  aorta,  is  covered  by  the  pleura,  and  il  the  aneurism  is  in  the  ab- 
domen, by  the  peritoneum  ;  which  membranes  include  the  ai  eu- 
rismal  sac,  together  with  the  ruptured  artery,  and  present  exter- 
nally, a  continued,  smooth,  shining  suilace,  as  if  the  artery  alone 
was  in  that  way  dilated. 

u  But  if,  instead  of  dividing,  as  is  commonly  done,  the  Fundus 
of  the  aneurismal  sac,  the  aorta  be  divided  lengthwise  on  the  other 
side,  and  opposite  to  the  constriction  or  neck  of  the  tumour,  the 
place  of  the  ulceration,  or  of  the  rupture  of  the  pioper  coats  of  the 
artery,  immediately  appears  within  the  artery,  on  the  side  opposite 
to  that  where  the  incision  was  made,  and  the  fissure  which  hi.«s  taken 
place  is  immediately  discovered,  the  edge  of  which  is  sometimes 
fringed,  often  callous  and  hard,  like  that  of  a  fistula  ;  through  which 
fissure  the  arterial  blood  had  formed  itself  a  passage  into  the  cellu- 
lar sheath  of  the  artery,  afterwards  converted  into  an  aneurismal  sac. 
If,  as  sometimes  happens  in  the  arch  of  the  aorta  in  the  vicinity  of 
the  heart,  the  artery,  before  being  ruptured,  has  suffered  some  de- 
gree of  enlargement  beyond  its  usual  diameter,  it  appears  at  first 
sight  that  there  art  two  aneurisms  ;  but  the  constriction  or  neck 
which  the  aneurismal  sac  next  to  the  artery  presents  externally, 
pomls  out  exactly  the  limits,  beyond  which  the  internal  and  muscu- 
lar coat  of  the  aorta  had  not  been  able  to  resist  the  distention,  and 
have  therefore  been  torn  by  it,  and  shows  clearly  the  difference  ex- 
isting between  an  aneurism  and  a  simple  enlargement  in  diameter  of 
the  tube  of  the  aorta  in  the  vicinity  of  the  heart. 

"  The  rupture  in  the  artery  is  always  small  in  proportion  to 
the  large  size  of  the  aneurismal  tumour  ;  so  that  when  the  arch  of 
the  aorta  has  suffered  some  degree  of  dilatation  before  bursting,  as 
sometimes  happens  near  its  passage  out  of  tie  heart,  on  making  an 
incision  on  one  side  into  the  aneurismal  sac,  and  on  ihe  other  into 
the  tube  of  the  artery  lengthwise,  two  sacs  present  themselves,  se- 
parated from  each  other  by  means  of  a  partition  or  diaphragm  lace- 
rated in  its  middle  ;  which  partition  is  formed  of  nothing  else  than 
the  remains  of  the  internal  and  muscular  coats  of  the  tuptuied  arte- 
ry. And  as  the  limits  of  the  proper  coats  of  the  aorta,  and  the  be- 
ginning of  the  cellular  aneurismal  sac,  are  marked  externally  by 
that  kind  of  constriction  or  neck  which  the  tumour  presents  in  the 
vicinity  of  the  artery  ;  in  the  same  manner,  internally,  this  partition, 


558  -iftjiendix. 

torn  in  its  middle,  determines  the  precise  point  of  the  rupture  of  the 
ptoper  corns  of  the  artery  occupied  by  aneurism. 

"  All   this   acquires   a   degree   of  demonstration   and  certainty, 
to  winch  Homing  cum  be  opposed,  by  carefully  dissecting  the  proper 
coals  of  the  ruptured  aorta  in  us  situation,  and  compaung  them  at 
the  same  time  with  the  cellular  substance  forming  the  aneurysmal 
sac  ;  for,  in  the  incision  made  in  tne  direction  of  the  axis  of  the  aor- 
ta, and  in  its  side  opposite  10  that  wiiere  the  rupture  has  taken  place, 
its  proper  coats  are  found  either  perfectly  sound,  or  a  little  weaken- 
ed and  intermixed  with  earthy  points,  but  still  capable  of  being  se- 
parated distinctly   into  layers  from  one  auolher ;  when,  on  the  con- 
trary,  in  tiic  opposite  side  of  the  aorta,  where  the  ulceration  or  lace- 
ration exists,  its  proper  coats  are  met  with  unusually  thin,  blended 
togetner,  and  with  difficulty,  or  in  no  way  capable  of  being  separat- 
ed from  each  other,  intermixed  very  often  with  heterogeneous  sub- 
stances, which  render  them  brittle  like  the  shell  of  an  egg;  and, 
lastly,  disorganized  and  torn  at  the  place  where  they  form  mat  spe- 
cies of  partition,  which  marks  the  limits  between  the  ruptured  artery 
and  me  entrance  of  the  aneurismal  sac.     Continuing   to    separate 
these  coals  from  within  outwards,  we  come  to  the  cellular  sheath 
Which  surrounds  the  aorta  externally.      1  hen,  on  removing  the  cel- 
lular pulpy  sheath  of  tne  aorta,  it  is  found  smooth  externally,  like 
tile    artery,  villous,    cellular,    and   irregular    internally,    extending 
from  the  circumference  of  the  tube  of  the  artery   over  the  neck  and 
fundus  ot   the  aneurismal  sac.     Tins  external  covering  or  sheath  of 
tiie  artery  actually  appears,  to  those  who  are  not  sufficiently  skilled 
in  such  dissections,  as  if  the  artery  were  dilated  under  it  to  such  a 
degree  as  to  form  the  aneurism  ;  and  it  has  still  more  that  appear- 
ance if  tne  aneurism  is  very  large  and  of  long  standing,  since  in  this 
case  the  cellular  sneath  ot  tne  artery  becomes  unusually  thick  and 
pulpy,  and  because  it  adheres  very  fiimly  to  the  suojacent  muscular 
coat  jf  tne  artery  at  the  stricture  or  neck  of  the  aneurismal  sac— 
But  even  in  these  cases,  as  well  as  in  those  of  recent  and  small  an- 
eurisms of  the  aorta,  by  employing  care,  we  may  at  least  succeed  in 
separating,  witnout  laceration,  this  cellular  sheath  from  the  tube  of 
the  ariery,  above  and  below  the  injury,  and  successively  from  the 
subjacent  muscular  coat,  as  fur  as  the  neck  or  root  of  the  aneurism. 
It  is  then  clearly  perceived  that  tne  muscular  coat  ot  the  aorta  does 
not  pass  beyond  the  partition  which  divides  its  tube  from  the  en- 
trance <){  the  aneurismal  sac  ;  and  it  is  distinctly  observed,  that  the 
fibres  and  iayers  of  the  muscular  coat  aie  not  prolonged  over  the  an- 
eurismal  sac,  but  terminate  like  a  fringe,  or  in  obtuse  points,  at  the 
edge  of  the  rupture  of  the  artery.     On  which  account,  nothing  can 
be  more  evident  than  that  the  aneurismal  sac  does  not  belong  at  all 
to  the  artery,  and   that,  properly  speaking,  it   is  only  the  cellular 
sheath,  which  in  the  sound  state  covered  and  connected  the  artery 
to  the  neighbouring  parts  which  being  elevaied  by  the  effused  blood, 
at  hVst  in  the  manner  ol  an  ecchymoiis,  then  distended  and  compress- 
ed, has  acquired  that  degree  of  density,  and  of  additional  hardness 


Appendix.     '  559 

and  thickness,  as  if  it  had  been  formed  by  the  proper  coats  of  the  ar- 
tery, prodigiously  related,  distended,  and  thickened.  Thtse  ap- 
pearances the  more  readily  lead  to  error,  as  both  the  injured  artery 
and  the  aneurismal  sac,  as  has  been  frequently  mentioned,  are  co- 
vered bv  a  common  smooth  membrane  e.  ternally,  such  as  the  pleura 
in  the  thorax,  and  the  peritoneum  in  the  abdomen. 

"  From  all  that  has  been  hitherto  said  with  regard  to  aneurism 
in  general,  and  more  particularly  of  that  of  the  aorta,  it  appears  to 
me,  that  we  may  with  certainty  conclude,  1st,  That  this  disease  is 
invariably  formed  by  the  rupture  of  the  proper  coats  of  the  artery. 
2dly,  That  the  aneurismal  sac  is  never  formed  by  a  dilatation  of  the 
proper  coats  of  the  artery,  but  undoubtedly  by  the  cellular  sheath 
which  the  artery  receives  in  common  with  the  parts  contiguous  to  it ; 
over  which  cellular  sheath  the  pleura  is  placed  in  the  thorax,  and  the 
peritoneum  in  the  abdomen  3dJy,  That  if  the  aorta  immediately 
above  the  heart  appears  sometimes  increased  beyond  its  natural  di- 
ameter, this  is  not  common  to  all  the  rest  of  the  artery  ;  and  when 
the  aorta  in  the  vicinity  of  the  heart  yields  to  a  dilatation  greater 
than  natural,  this  dilatation  does  not  constitute,  properly  speaking, 
the  essence  of  aneurism.  4thly,  That  there  are  none  of  those  marks 
regarded  by  medical  men  as  chaiacteristic  of  aneurism  from  dilata- 
tion, which  may  not  be  met  with  in  aneurism  from  ru/iture,  including 
even  the  circumscribed  figure  of  the  tumour.  5thly,  '1  hat  the  dis- 
tinction of  aneurism  into  true  and  xfturicus,  adopted  in  the  schools,  is 
only  the  production  of  a  false  theory  ;  since  observation  shows,  that 
there  is  only  one  form  of  this  disease,  or  that  caused  by  a  rupture  of 
the  proper  coats  of  the  artery,  and  an  effusion  of  arterial  blood  into 
the  cellular  sheath  which  surrounds  the  ruptured  artery." 

tf  E 

This  figure,  I  am  satisfied  from  the  description,  although  the  au- 
thor is  not  cited,  refers  to  a  supposed  case  of  dilatation  of  the  coats 
of  an  artery  by  Dr.  Donald  Monro.  The  following  is  an  account  of 
a  dissection  of  that  case  by  Monro  the  father.  The  account  is  giveH 
in  a  letter  to  the  son  who  had  sent  the  parts  to  Edinburgh  to  be  dis- 
sected. 

"  The  aneurismal  sacs  you  sent  to  Edinburgh  were  dissected  by 
your  brother,  in  my  presence  ;  the  appearances  were  the  following. 
The  external  loose  cellular,  and  the  cellulo-niembranous  coats  being 
dissected  away  carefully,  the  circular  fibrous,  commonly  called  the 
muscular  coat,  was  evidently  continued  on  all  the  three  small  sacs, 
in  every  part  of  them,  but  was  thicker  thtjre  than  in  the  sound  pan 
of  the  artery,"  and  what  is  worthy  of  the  greatest  attention,  "in  the 
most  enlarged  part  of  the  sacs,  an  extraneous  substance,  resembling 
a  soft  steatomatous  matter  was  intei  mixed  with  the  muscular  fibres. 
The  cellular  substance  being  the  inside  of  the  muscular  coat,  was 
considerably  thicker  than  natural,  and  had  much  tfee  appearance  of 


560  .      jljijiendix. 

an  extraneous  substance  filling  its  cells.  The  internal  membrane  of 
the  artery  adhered  so  firmly  to  these  cells,  that  it  could  not  be  se- 
parated,  hut  seemed  thicker  than  in  a  sound  state." 

From  the  foregoing  account  we  a>e  at  a  loss  to  determine  whether 
the  artery  was  dilated  at  these  enlargements.  Scarpa  says  it  cer- 
tainly was  not. 


DIRECTIONS  FOR   PERFORMING    THE  OPERATION  FOR    POPLITEAL 

ANEURISM. 

Having  prepared  the  patient,  if  he  be  at  all  plethoric,  by  low  diet 
and  the  administration  of  purgative  medicines,  you  provide  yourself 
with  the  following  apparatus  ;  a  common  convex  edged  bistoury,  an 
eyed  probe,  two  of  the  smallest  sized  needles,  each  armed  with  a 
waxed  ligature  of  moderate  thickness,  a  tenaculum  with  a  few  ordin- 
ary ligatures  some  straps  of  sticking  plaster,  a  little  lint  and  a  six- 
tailed  bandage.  Tye  the  two  ligatures  together  which  are  provi- 
ded with  needles,  then  pass  the  knot  through  the  eye  of  the  probe 
and  secure  it  there  in  such  a  manner  that  the  ligatures  will  be  of 
equal  length,  and  cannot  slip. 

The  patient  is  to  be  placed  upon  a  table  near  its  edge,  with  his 
head  somewhat  elevated,  and  the  leg  and  thigh  of  the  affected 
side  in  a  state  of  semiflexion  and  supported  on  a  pillow.  The  surgeon 
should  ascertain  the  course  of  the  artery  by  feeling  its  pulsation  as 
it  passes  from  under  the  crural  arch  down  on  the  inner  side  of  the 
thigh.  The  incision  which  is  to  be  about  three  inches  in  length, 
is  to  be  made  along  the  inner  edge  of  the  sartorius  muscle  ia  such 
a  manner  that  the  inferior  angle  of  the  wound  will  just  reach  the 
apex  of  the  triangle  formed  by  the  convergence  of  the  adductor 
brevis  and  vastus  interims  of  the  thigh.  The  first  incision  should 
be  of  sufficient  depth  to  expose  the  fascia  lata  of  the  thigh,  the 
next  stroke  of  the  knife  will  lay  open  this  and  expose  the  fibres  of 
the  sartorius  muscle  which  covers  the  artery  in  some  degree,  which 
is  therefore  to  be  drawn  outward:  this  immediately  exposes  the 
tendinous  sheath  which  incloses  the  artery,  vein,  and  anierior  cru- 
ral nerve.  This  sheath  is  to  be  very  cautiously  opened  for  about  an 
inch,  and  then  the  artery  is  to  be  completely  separated  from  the 
vein  and  nerve  with  the  nail,  or  handle  of  the  scalpel  so  as  to  avoid 
wounding  the  coats  of  t tie  vessel.  The  probe  being  gently  curved 
is  now  passed  under  the  artery,  and  the  two  ligatures  are  thus  car- 
ried under  the  vessel  which  must  now  be  separated  from  the  probe 
and  from  each  other.  One  ligature  is  to  be  cariied  as  high  as  pos- 
sible on  the  artery,  and  the  other  as  low  down,  and  then  the  surgeon 
having  satisfied  himself  that  the  ligatures  include  nothing  but  the 
naiied  vessel,  he  proceeds  to  tye  the  upper  one  with  considerable 
firmness  and  an  ordinary  knot.     Should  he  apprehend  the  ligature's 


Jjijiendix,  561 

being  thrown  off,  let  him  pass  the  needle  through  the  coats  of  the 
artery  and  tie  another  knot  which  will  effectually  prevent  it.  The 
lower  ligature  is  now  to  be  tied  in  the  same  manner,  and  then  the 
vessel  is  to  be  divided  and  suffered  to  retract.  The  ligatures  are  to 
be  left  of  a  moderate  length  hanging  out  from  each  angle  of  the 
wound  which  is  to  be  drawn  together  with  straps  of  sticking-plaster, 
and  the  whole  secured  by  the  six-tailed  bandage.  A  small  dose  ol" 
opium  may  be  administered  after  the  patient  is  carried  to  bed, 
where  he  is  to  be  kept  in  a  state  of  1  est,  and  upon  low  diet  for  some 
time.  The  limb  is  to  be  kept  in  the  easiest  position  with  a  tourni- 
quet around  vt,  in  Case  of  accident,  and  covered  w  ith  flannel.  Should 
it  become  very  cold,  bladders  filled  with  warm  water  are  to  be  ap- 
plied.   . 

Immediately  after  the  first  ligature  is  tied,  all  pulsation  ceases  in 
the  aneurism,  which  after  some  days,  begins  to  diminish  and  is  ul- 
timately absorbed. 

This  is  the  method  of  securing  every  artery  where  it  is  tied  at  a 
distance  from  ihe  aneurism  ;  when  it  is  necessary  to  open  the  aneu- 
rysmal sac,  a  different  plan  is  to  be  pursued. 


t 


G 


When  the  thigh-bone  is  luxated,  and  the  head  of  it  is  lodged 
either  upon  the  os  pubis,  or  in  the  foramen  thyroideum,  ft  may  be 
reduced  in  the  following  manner. 

The  patient  is  to  be  extended,  upon  his  back,  upon  a  firm  table,  a 
broad  bandage  is  then  to  be  passed  around  the  pelvis,  the  two  ends  of 
which  are  to  be  made  fast  to  8  pillar,  or  some  other  firm  object  on  the 
side  of  the  patient,  opposite  to  the  luxated  extremity.  -Another 
bandage  is  to  be  passed  around  the  dislocated  thigh  as  high  as  possi- 
ble, that  is  in* contact  with  the  perinxum  which  is  to  be  securtd  in 
the  same  manner  as  the  other,  but  on  the  opposite  side  The  ban- 
dages should  be  made  of  such  materials  and  drawn  so  lighly  as  not 
to  yield,  when  the  attempt  to  reduce  the  luxation  is  made  This 
is  to  be  done  by  extending  the  leg  upon  the  thigh  and  then  using 
the  whole  limb  as  a  lever,  in  which  the  resistance  is  at  one  end,  the 
power  at  the  other,  and  the  fulcrum,  which  is  the  bandage  around  the 
luxated  limb,  in  the  middle,  which  is  done  by  forcing  the  luxated 
limb  suddenly  and  smartly  across  the  other.  In  this  way,  if  the  ban- 
dages are  properly  fixed  and  of  sufficient  strength,  any  requisite  de- 
gree of  force  maybe  applied.  This  method  of  reduction  1  have  seen 
practised  by  Mr.   Astley  Cooper  with  succes.s. 

But  when  the  head  of  the  thighbone  is  lodged  in,  the  ischiatic 
notch  or  upon  the  dorsum  of  the  ileum,  then  recourse  must  be  had  to 
other  and  more  effectual  means.  The  first  thing  to  be  attended  to  is 
the  fixing  of  the  pelvis.  If  this  is  attempted  with  bandages  only,  the 
table  on  which  the  patient  is  placed  must  be  very  heavy  and  strong, 
a'ul  the  bandages  must  he  sufficiently  long  to  fasten  him  securely  to  it. 

4   B 


562  Ahjiendiv. 

A  better  plan  has,  I  think,  been  recommended,  of  making  the  pa- 
tient sit  astride  a  beam  wrapped  round  with  cloths  sufficient  to  pre- 
vent injury  to  the  perinxum.  The  extension,  which  must  be  very 
powerful  and  long  continued,  and  more  depends  lipoid  the  length  of 
time  than  the  degree  of  force,  is  to  be  made  downwards  and  out- 
wards, in  the  latter  direction  first,  to  detach  the  bone  from  its  unna- 
tural position,  and  enable  it  when  the  force  acting  downwards  is  ap- 
plied, to  slip  over  the  edge  of  the  acetabulum  into  the  socket.  In 
order  to  diminish  the  resistance  from  the  muscles,  various  remedies 
have  been  used,  of  these,  bleeding  to  as  great  an  extent  as  the  patient 
can  conveniently  bear,  is  by  far  the  best.  Fainting  should  be  brought 
on,  if  practicable,  without  too  great  a  loss  of  blood.  'Tobacco  in- 
jections have  proved  fatal  and  Ought  therefore,  I  think,  never  to  be 
used. 


FINIS. 


COLLINS  &  CO. 

Announce  to  the  Medical  Profession,  that  theij  have  been  indiC 
ced  to  turn  their  attention  to  the  sale  of 

MEDICAL,  CHEMICAL,  AND  BOTANICAL  BOOKS, 

In  confcqucncc  of  the  folicitations  of  many  of  the  moft  refpectable 
of  the  Faculty. 

Whilft  they  refpectfully  folicit  the  further  patronage  of  the  Profcffion  at  large, 
the  advertifers  fhould,  with  gratitude,  acknowledge  the  very  extenfive  encourage- 
ment which  they  have  already  received.  Their  obligations  are  due,  not  ojily  to 
the  different  medical  profeflors  and  lecturers  of  the  two  Colleges  in  New- York, 
who  in  their  private  capacity,  have  recommended  their  efbblifhment,  but  alfo  to 
medical  inftitutions,  which  have  promoted  their  undertaking,  by  officially  con- 
flicting the  advertiferi  their  printers  and  medical  bookfeilers. 

With  regard  to  charges,  thofe  for  American  books,  it  is  obvious,  muft  be  regu- 
lated by  the. prices  adopted  by  their  publifhcrs;  but  foreign  books  are  priced  by 
the  importer.  To  thofe  of  the  Faculty  who  have  already  dealt  with  the  adver- 
tifers, it  may  be  fufficient  to  obferve,  that  they  pledge  themfclves  to  continue  to 
fell  on  the  fame  favourable  terms  as  heretofore. 

Upon  American  editions,  (periodical  publications  and  a  few  others  excepted)  li- 
bera] difcounts  will  be  allowed  to  wholcfale  purchafers  :  but  upon  imported  books, 
fuch  are  their  prefent  .reduced  retail  prices,  that  but  a  very  fmall  difcour.t  can  be 
afforded.  Hid  the  advertifers  adopt  the  practice  of  marking  imported  books  as 
much  above  their  cost  as  are  thofe  of  American  origin,  the  fame  large  difcounts 
could  with  equal  propriety  be  allowed:  but  they  apprehend  that  fuch  a  fyftcm  is 
not  calculated  to  difpenfe  equal  jufrice  to  all,  nor  to  enable  the  purchafer  of  a  An- 
gle book  to  poflefshimfelf  of  it  :.t  a  price  ior  which  it  can  be  fairly  afforded. 

For  Sale  by  the  Publishers  of  this  Work, 

Price  Eleven  Dollars,  handfomely  bound  and  lettered, 

THE  ANATOMY  OF  THE  HUMAN  BODY, 

Illustrated  with  One  Hundred  and  Twenty-Five  Engravings. 

IN    FOUR    VOLUMES,    BOUND    IN    TWO. 

By  JOHN  &  CHARLES  BELL, 

From  the  last  London,  Edition,  improved  by 
the  Author. 

In  the  execution  of  the  above  valuable  and  popular  work,  Collins  &  Co.  have 
fpared  neither  labour  nor  expenfe,  to  render  it  luperior  to  the  London  copy.  They 
have  corrected  feveral  hundred  important  typographical  errors.  Many  of  the  en- 
gravings are  pronounced  by  competent  judges  to  be  muchfuperior  to  the  original, 
and  yet  the  price  is  lefs  than  half. 

Of  the  character  of  Bell's  Anatomy,  it  may  not  become  the  publifhers  to  fay 
any  thing.     The  following  extracts  will  fatisfy  every  enquirer  :— 

"  It  would  be  injuftice  to  confound  this  work  with  the  ordinary  compilation*5 
from  the  common  Hock  of  elementary  writers,  and  the  tranferibed  lectures  of  the 
Clafs  Room.  It  is  obvioufly  the  rcfult  of  very  extenfive  ftudy,  both  in  books  and 
in  the  Differing  Room,  and  its  completion  now  fupplies  a  want  very  much  felt  by 
the  Lnglifh  Reader."  Adins  Annual  Review. 

"  The  four  volumes  by  John  &  Charles  Bell,  form  a  Tody  of  Anatomy,  greatly 
fuperior  to  any  at  prefent  to  be  found  in  our  language.  By  judicioufly  blending 
the  phyfiology  or  doctrine  of  functions  with  the  Anatomical  defcriptions,  by  fre- 
quent occafional  reference  to  pathology  and  practice,  ar.d  by  a  manner  peculiarly 
impreffive  and   intercfting,  they  have   been  enabled  to  excite  the  attention  of  the 


Student  to  a  fubject  of  the  utmoft  importance  to  tkc  healing  art ;  but  one  which  is 
rendered  dry  and  difgufting  by  the  ordinary  mode  oi'  treating  it." 

London   Medical  Review. 

"  We  moft  fincerely  congratulate  the  public  on  the  profpect  of  acquiring  this 
fplendid  improvement  in  the  means  of  cultivating  Anatomy  and  Phyfiology  in 
every  part  of  our  country,  as  we  are  confident  that  die  general  circulation  ol  this 
work  would  be  alone  fufficient  to  advance,  in  a  confideteble  degree,  the  refpe&a- 
bilijy  and  ufefulnefs  of  the  Medical  profeflion  in  this  new  world." 

Mi  Jical  Repository.  . 

THE  MODERN  PRACTICE  OF  PHYSIC; 

Exhibiting  the  characters,  causes,  symjitoms,  prognostics,  morbid  appear- 
ances, and  improved  methods  of  treating  the  disea^"s  oj  all  climates, 

BY  ROBERT  THOMAS,  M.  D. 

Third  Englifli  edition,  corrected   and  confiderably  enlarged  by  the  author. 

To  which  is  added  AN  APPENDIX, 
BY  EDWARD  MILLER,  M.  D. 

Frofejfor  of  the  Praclice   of  Phyfic  in  the  Univerfity  of  NetvYori,  Phyfcian  in    the 
'     '  New-York  Hospital,  &c.  KV. 

So  high  is  the  cftimation  in  which  the  prefent  work  is  held  by  the  medical  pro- 
feflion  in  England,  that  three  very  large  editions  have  during  the  fliurt  time  ftnee 
its  publication,  already  been  printed,  It  is  r.prefcnted  by  different  medical  critics, 
as  exhibiting  a  very  correct  view  of  the  prefent  ftate  of  medical  fcirncc  in  Great- 
Britain,  and  as  conderiing,  in  a  fmal!  compafs,  more  practical  information  than  any 
work  which  has  preceded  it.  The  author,  however,  in  his  account  of  certain  dif- 
eafes,  and  methods  of  treatment,  of  which  much  experience  has  been  had  in  this 
country,  is  believed  to  have  committed  fome  miftakes  from  inadvertency  and  mif- 
information.  The  defign  of  the  Appendix,  by  Dr.  Miller,  therefore,  is,  to  correct 
thefe  mistakes,  and  to  ftate  fome  opinions  which,  it  is  hoped,  will  meet  with  the 
approbation  of  the  author. 

It  is  no  inconfiderable  recommendation  of  the  prefent  work,  that  it  is  the  only 
treatife  on  the  practice  of  phyfic,republifhed  in  this  country,  which  has  been  writ- 
tefi  within  the  laft  fixteen  years. 

The  price  is  four  dollars ;  though  the  Englifli  edition,  executed  on  paper  much 
inferior,  fells  at  fix  dollars. 

The  following  recommendations  are  taken  from  the  Reviews. 

"  A  treatife  nearly  univerfal  in  its  object,  has  been  particularly  defirable,  and 
Doctor  Thomas  having  hud  opportunities  of  actually  obferving  the  difeafes  and 
practice  of  different  countries,  but  tfnecially  thofe  of  hot  climates,  and  being  con- 
verfant  with  the  writings  ol  our  belt  modern  authors  and  teachers,  may  be  confider- 
ed  as  well  qualified  to  undertake  fo  important  a  talk.  We  think  Dr.  Thomas  has 
acquitted  himfelf  of  his  undertaking  in  a  manner  highly  creditable  to  him  as  a  man 
of  refearch,  and  as  a  Practical  Phyfician,  and  that  his  work  deferves  to  ftand  high 
in  the  catalogue  of  this  kind  of  compilation." — London  Medical  Review. 

"  In  compilations  of  this  fort,  it  is  fufficient  that,  in  addition  to  a  clear  and  me- 
thodical arrangement,  due  diligence  be  employed  in  collecting  from  the  proper 
fources,  and  judgment  in  difcriminating  between  real  and  pretended  difcoveries. 
In  thefe  refpect^.  we  think  the  author  of  the  prefent  work  has  not  been  deficient. 
It  is  a  compendium  of  the  exifling  doctrines  and  practice  of  medicine." 

Medical  and  Cbirurgical 


1 


♦ 


1 


> 


i 


s 


( 


Date  Due 


/-.            -.. 

'" 

Form  335 — 35M — 9-34 — C.  P.  Co. 

517  B4333 
Bell 


298871 


Principles  of  Surgery 


617     B4  3S 


293371 


■•', 


Jv*l 


til 


'  * 


«« 


